Burnaby City Dentist

Dentist Referrals

Call (604) 432-9223

Request Appointment

Refer Your Patients To Burnaby City Dentist Today

Complete this form to refer your patient to our specialists.

Contact Information For Burnaby City Dentist

Burnaby City Dentist
4361 Kingsway, #1
Burnaby, BC V5H 1Z9

(604) 432-9223
info@burnabycitydentist.com

"*" indicates required fields

Patient Information

Patient's Name*

First Last

Patient's Date of Birth*

Patient's Address

Street Address Address Line 2 City Province Postal Code

Patient's Phone (Home)

Patient's Phone (Cell)

Patient's Email

Referring Doctor Information

Doctor's Name*

First Last

Practice Address

Street Address Address Line 2 City Province Postal Code

Practice Email*

Practice Phone*

Referral Details

Which Doctor is this referral for?*

Reason for Referral

Full mouth rehabilitation

Cosmetic Solutions

Implant Restorations

Implant Surgery

Other reason for referral

3D CBCT (cone Beam Computed Tomography)

Single Site

Single Arch

Dual Arch

Area(s) of Particular Interest

To select multiple teeth, press and hold the Ctrl or Cmd key while selecting.

Anticipated Procedure

Additional Comments

Patient Files

Maximum 2 (two) files, not greater than 8MB each file.

Drop files here or

Max. file size: 8 MB, Max. files: 2.

Name

This field is for validation purposes and should be left unchanged.

New Patients Welcome

Take Care Of Your Oral Health & Book Your Dental Hygiene Appointment Today

Centrally & Conveniently Located
Free Parking
Open Saturdays
IV Sedation

Call (604) 432-9223

Request Appointment

1-1
1-2
1-3
1-4
1-5
1-6
1-7
1-8
2-1
2-2
2-3
2-4
2-5
2-6
2-7
2-8
3-1
3-2
3-3
3-4
3-5
3-6
3-7
3-8
4-1
4-2
4-3
4-4
4-5
4-6
4-7
4-8