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 
 Guardian
 Relationship to patient
 
 
 
 Patient Name
 Birthdate
 
 
 
 

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