Sorting

First and last name

Note: the sentences in italic are for guidance (do not tell the parent).
CHILD INFORMATION
PARENT INFORMATION
REASON FOR CONSULTATION
Please ask him/her to complete it, on our website. Whether you don't hear from us in the next 4 weeks, call us back and we'll tell you what to do.
Emergency? Remind the parent that the referral form must still be completed, before the appointment.

Please save the referral form in pdf or image format and attach it to this form.

"I'm going to ask you a few questions to better guide your child's care. The answers given will have no impact on the time of the appointment."
3) Does he/she understands and follow simple instructions, such as:

If patient is collaborative, open mouth, sitit on the chair and does not overreact during hygiene care (3), make an appointment as normal for the PMS patient. As soon as one of the 4 questions demonstrates difficulties for the child, send the triage form to Sandy and mention:
“The clinical coordinator will take care of establishing the most suitable course of care for your child by giving him a personalized appointment sequence. If deemed necessary, an additional form will be emailed to you and must be returned to the clinic. »

If you assess that a patient is in a financial or social vulnerability, mention:
“We will transfer your request to the community coordinator, who will call you to inform you of the process and the eligibility criteria for access the SDC program – an assistance program that offers all free dental care through an authorized referring organization."

TO WHOM TO SEND THE FORM?

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