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About Us
Meet Dr.Wong
Meet The Team
About the Specialty
Services
Routine Care
Emergency
Fillings
Crowns
Nerve Treatment
Extractions and Space Maintainers
Silver Diamine Fluoride
Sedation
Tongue & Lip Ties
Referring Doctors
Contact
Book Now
About Us
Meet Dr.Wong
Meet The Team
About the Specialty
Services
Routine Care
Emergency
Fillings
Crowns
Nerve Treatment
Extractions and Space Maintainers
Silver Diamine Fluoride
Sedation
Tongue & Lip Ties
Referring Doctors
Contact
Book Appointment
Referring Doctors
Need to submit your referring doctors information? we have two options. You can either print and bring in your referral form or you can fill out the form below.
Print Referral Form
Doctor Name
*
Dental Office
Referral Phone Number
Referring Office Email
*
Referral Date
Patient Name
*
DOB
*
Legal Guardian
*
Address
*
Phone Number
*
Email Address
*
Reason For Referral
Establishment of a Dental Home
Severe Early Childhood Caries (SECC)
Dental Trauma
Special Health Care Needs
Permanent Dentition Decay
Nitrous Oxide and Oxygen Sedation/Oral Sedation/General Anesthesia
Oral Pathology
Radiographs
Not Available
X-Rays Emailed
Date Radiographs Taken
Insurance Information
Subscriber Name
Subscriber DOB
Insurance Carrier (ex. Sunlife, Manulife)
Group ID/Policy Number
Certificate/Member#
Submit Form