Referral Form - Okanagan Pediatric Dentistry

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General Anesthesia

Refer A Patient

✕

Unit 101 – 1890 Cooper Road, Kelowna, BC V1Y 8B7
Tel (250) 763-5101
Fax (250) 763-5131
info@opdentistry.ca
Find us on

1890 Cooper Rd #101, Kelowna, BC V1Y 8B7

|

Tel (250) 763-5101

|

Fax (250) 763-5131

|

info@opdentistry.ca

|

Home
Meet Dr. Farquhar
Services
Diagnostic & Preventive Services
Behavior & Comfort Management
Restorative & Specialized Treatments
General Anesthesia
First Visit
Education
Contact Us

General Anesthesia

Refer A Patient

Patient Referral

Printable Referral Form

Date Of Referral(Required)

DD slash MM slash YYYY

Consultation Request For(Required)

Gender(Required)

Date Of Birth(Required)

DD slash MM slash YYYY

Address(Required)

Street Address Address Line 2 City Province Postal Code

Email(Required)

Phone (Home)

Phone (Mobile)(Required)

Parent/Guardian Name(s)(Required)

Dental Insurance(Required)

Yes

No

BC Care Card(Required)

First Nations Status

Primary Insurance Company

Subscriber Full Name

Date of Birth

DD slash MM slash YYYY

Policy/Group

Member ID/Certificate

Secondary Insurance Company

Subscriber Full Name

Date of Birth

DD slash MM slash YYYY

Policy/Group

Member ID/Certificate

Radiographs(Required)

Digital (please attach below or email)

Mailed

Not Taken

Given to Parent

Medical Alerts Or Allergies

Neurodivergent

Yes

No

Reason For Referral(Required)

Dental Caries

Dental Trauma

Behaviour Guidance

Guidance of Occlusion

Other

Other Reason for Referral

Treatment Modality Requested By, Or Recommended To Parent(Required)

Behaviour guidance and local anesthesia

Sedation and local anesthesia

General anesthesia

None requested/Recommended

Other

Other Treatment Modality Requested By, Or Recommended To Parent

X-ray(s) Date taken

MM slash DD slash YYYY

Additional Notes Or Specific Concerns

Referring Doctor(Required)

Clinic Phone(Required)

Clinic Name(Required)

Clinic Email(Required)

X-Rays & Other Relevant Documents

Drop files here or

Max. file size: 2 MB.

**We will plan to send treatment reports by email if possible, please ensure we have your correct email address.

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Our Clinic Address

1890 Cooper Rd #101
 Kelowna, BC V1Y 8B7

Phone

(250) 763-5101

Email

info@opdentistry.ca

Operating Room
Booking Department

Summerland (SHC)

(250) 404-8000

Kelowna (KGH)

(250) 980-1524

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Restorative and Specialized Treatments

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Home
Meet Dr. Farquhar
Services
First Visit
Education
Contact Us

General Anesthesia

Refer A Patient

1890 Cooper Rd #101
Kelowna, BC V1Y 8B7

Tel (250) 763-5101

Fax (250) 763-5131

info@opdentistry.ca