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

Email

Phone Number

Patient Name

Birthdate

Address

City

Postal Code

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

Phone

18	17	16	15	14	13	12	11	21	22	23	24	25	26	27	28
48	47	46	45	44	43	42	41	31	32	33	34	35	36	37	38

55	54	53	52	51	61	62	63	64	65
85	84	83	82	81	71	72	73	74	75

Patient Information:

Dental Insurance Information:

Reason for Referral:

18	17	16	15	14	13	12	11	21	22	23	24	25	26	27	28
48	47	46	45	44	43	42	41	31	32	33	34	35	36	37	38

18	17	16	15	14	13	12	11	21	22	23	24	25	26	27	28
48	47	46	45	44	43	42	41	31	32	33	34	35	36	37	38

18	17	16	15	14	13	12	11	21	22	23	24	25	26	27	28
48	47	46	45	44	43	42	41	31	32	33	34	35	36	37	38