Referral - Sourires Solidaires

— Patient to be referred

First Name*

Laste 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

Medical/dental history summary *

— 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

Refugee status

Economic situation

General anesthesia/sedation service

Other

Specify

Social context of the child

—Referrer

Attach x-rays

No x-rays in hand - will be taken and sent afterwards (clinique@cliniquesoso.com)

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)

Referrer name*

Phone*

Email*

Reference date*

— Verification

Please enter the characters*

This field should be left blank

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