Andrew Tomash, DDS, FRCD(C)

Certified Specialist in Pediatric Dentistry
and Associates
​ Telephone: 250-595-3322 Fax: 250-592-2186
    203-3550 Saanich Road

Dentist Referral:

Patient Information:

     Date of referral 
 Relationship to patient
 Patient Name

Dental Insurance Information:  


Second Dental Insurance Information:  


Reason for Referral:

Date of X-Ray  

     Please remind patients that NO treatment will be provided at the initial consultation