Referring Office Information:

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Referring Dentist Name(Required)

Office Phone Number

Office Email(Required)

Patient Information:

Patient First Name(Required)

Patient Last Name(Required)

Patient Phone Number

Patient Email

Insurance Carrier

Referral Details:

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Additional Notes(Required)

Attach X-rays

Max. file size: 490 MB.

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Site phone

Office Hours

Monday: 10:00am-8:00pm
Tuesday: 9:00am-5:00pm
Wed-thurs: 9:00am-5:00pm
Fri: 9:00am-4:00pm
Sat: CLOSED
Sun : CLOSED

Location

Suite 101, 1854
Southview Drive SE,
Medicine Hat, AB, T1A 8L9

Quick Links

All services provided by general dentists

Patient Referal Form