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.

1 - Please identify who you would like to refer to :
Periodontist (Dr Éric Lacoste)
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 Julie Leduc

Required care by Dr Éric Lessard

Required care by Dr Julien Ghannoum

Right   Left
 
 
 

4 - Performed tests and additional information

Required pivot space *

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)