New Patient InformationPlease enable JavaScript in your browser to complete this form.Patient Name *FirstLastContact Name (If not the same as patient name)FirstLastContact Email *Phone Number TypeCellHomeWorkContact Phone *Patient Date of Birth *Referring DentistI was referred by a dentistYesNoReferring Dentist Name *FirstLastReason for Referral *Radiographs Are *With patientAttachedNot availableRadiograph Files Click or drag files to this area to upload. You can upload up to 8 files. Select a file to upload (.doc, .docx, .jpg, .jpeg, .bmp, .tif, .pdf). File size limit 10 MB for a maximum of 8 files.Submit Referral We are Here to Help You218 Commissioners Rd. W.London ON, N6J 1Y1(519) 685-3060info@highlandortho.caMonday: 9:00am - 5:00pmTuesday: 1:00pm - 8:00pmWednesday: 9:00am - 5:00pmThursday: 9:00am - 5:00pm
