Thank you for referring your patients to us. Please fill in the electronic referral form below.
*Radiographs can be accepted electronically by emailing us at info@yukonchildrendentistry.ca
If you have any questions, please call us at 1 867 336 1360

    1. Date( MM/DD/YYYY) *

    2. Introducing *

    3. Birth Date (MM/DD/YYYY) *

    4. Guardian *

    5. Relationship *

    6. Address *

    7. City *

    8. Postal codes *

    9. Home phone *

    10. Other phone

    11. Email

    12. Reason for Referral / Comments *

    13. Radiographs*

    NoneMeditran/Doc Servicesby Mailwith Patientby Email
    If "by email" is selected, please email us at info@yukonchildrendentistry.ca with patient's name in subject line"

    14. Primary Insurance? *

    Yes (Please answer #15-#20)No (Please skip to #21)

    15. Name of insured

    16. Employer

    17. Plan name

    18. Policy no.

    19. ID no.

    20. % of Coverage

    21. Secondary Insurance? *

    Yes (Please answer #22-#27)No (Please skip to #28)

    22. Name of insured

    23. Employer

    24. Plan name

    25. Policy no.

    26. ID no.

    27. % of Coverage

    28. Referred by *

    29. Phone *

    30. Appointment date *

    Please contact patient for making an appointmentPatients to call to make an appointment

    31. Your office is located in? * (e.g. Vancouver BC)