Andrew Tomash, DDS, FRCD(C)

Certified Specialist in Pediatric Dentistry and Associates

Telephone: 250-595-3322 Fax: 250-592-2186

203-3550 Saanich Road
Email: info@islandkidsdental.com

Dentist Referral:

Patient Information:

Date of referral

Patient Name

Birthdate

Email

Phone Number

Address

City

Postal Code

Guardian

Relationship to patient

Carrier Name

Group #

Certificate ID Number

Policy Holder

Policy Holder Date of Birth

Employer

Carrier Name

Group #

Certificate ID Number

Policy Holder

Policy Holder Date of Birth

Employer

Restorations

Extractions (please indicate)

Consultation

Child has been difficult to handle

Will require general anesthetic

X-rays enclosed

No X-rays available

Date of X-Ray

Comments

Referred by Dr.

Referring Clinic Name

Phone

Email

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Patient Information:

Dental Insurance Information:

Second Dental Insurance Information:

Reason for Referral:

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