Referral - Sourires Solidaires

— Patient to be referred

First Name*

Last Name*

Child's date of birth*

Health insurance #

— Parent 1

Parent's name*

Main telephone number*

Cellular?*

Yes

Other phone number

Cellular?

Yes

— Parent 2

Parent's name

Main telephone number

Cellular?

Yes

Other phone number

Cellular?

Yes

— Contexte

Le patient était-il vu à votre clinique pour un :*

RDV d’urgence?

Suivi périodique?

Medical/dental history summary *

—Referrer

Attach x-rays

No x-rays in hand - will be taken and sent afterwards ([email protected])

Organisation name*

Specify*

Attach files here*

Files accepted: jpg, jpeg, png, pdf (10 MB maximum)

Attach a form/file

Files accepted: jpg, jpeg, png, pdf (10 MB maximum)

Program*

Attach a form/file

Files accepted: jpg, jpeg, png, pdf (10 MB maximum)

Nom de l’école*

Referrer name*

Phone*

# de poste

Email*

Reference date*

Diagnostic / Plan de traitement*

— Reasons for referral

The young age of the patient

The need for extensive restorations

The child's difficult or uncooperative behavior (anxiety, fear, etc.)

Diagnosis of a developmental disorder (autism, ADHD) or disability

General anesthesia/sedation service

Refugee status

Economic situation

Situation de négligence ou contexte social difficile

Other

N° UCI

Si vous avez coché "Statut de réfugié / Demandeur d’asile / PFSI", remplissez cette case

Specify

Social context of the child

Êtes-vous humain ?*

Adresse électronique*

This field should be left blank

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Laval (QC), H7T 2L1

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