Reference form

In order to accommodate you, the medical form that we ask you to complete when you arrive at the clinic is also available online. Please make sure that the required fields are completed correctly.

The information provided in this form will be kept strictly confidential by the clinic.

    1 - Please identify who you would like to refer to :
    Periodontist (Dr Éric Lacoste)
    Parodontiste (Dr Thomas Nguyen)
    Endodontist (Dr Julie Leduc)
    Oral Medecine (Dr Éric Lessard)
    Oral Pathologist (Dr Julien Ghannoum)
    2 - Patient information

    Do you have a preference for an Endodontist ?

    3 - Required care

    Required care by Dr Éric Lacoste

    Required care by Dr Thomas Nguyen

    Required care by Dr Julie Leduc

    Required care to be confirmed for Dr Julie Leduc

    Fistula

    Swelling

    Therapy started

    Periodontal pocket

    Required care by Dr Éric Lessard

    Required care by Dr Julien Ghannoum

    Right   Left
     
     
     
    4 - Performed tests and additional information

    Required pivot space *

    What type of obturation do you wish us to place?

    Type of shutter materials present

    Performed tests (must include adjacent teeth)
    Teeth #
    Cold
    Palpation
    Percussion
    Mobility
    Probing
    Tooth slooth
    5 - Radiography sent *

    Radiography : (maximum 2 mo by file)