(416) 538-8883
415 Bloor Street West Suite 300
Toronto, Ontario M5S 1X6

Patient Referral Form

We appreciate the confidence you show in us by referring your patient to our practice. Please use the below form to provide us with the Patient Information of whom you are referring. Alternatively, you could download the pdf and email us at dentistry@bloordental.com or directly mail us at our address.

If you need an Immediate Appointment, please call our office at (416) 538-8883 and talk to our staff and we will try to accommodate your patient.

Referring Doctor/Dentist

Doctor's Name*

Doctor's Telephone Number*

Doctor's Email Address*

Patient Information

Patient's Name*

Date of Birth:


Email Address*

Cell Phone*

Home Phone*

Insurance Coverage:*

Yes   |   No

Are there X-Rays Available?

Yes   |   No

Please send X-Rays to dentistry@bloordental.com

Radiographs to follow:

By Email   |   Via Post Mail

Reason for Referral:

Sleep Apnea
General Dentistry

We thank you for your referral and will contact your office to confirm intake. If there is anything we can do to serve you better, please let us know.

© Bloor Dental Health Centre - All Rights Reserved