缅北强奸
缅北强奸
Oral and Maxillofacial Surgery
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General OMFS
Maxillofacial Pathology
Implants
Patient Referral Form
Patient Information
First Name
*
Last Name
*
MEDICARE NUMBER (RAMQ)
Parent's Name (if applicable)
Email Address
*
Phone Number
Home
*
Work
Cell
Birthday (dd/mm/yy)
*
Referring Doctor Information
First Name
*
Last Name
*
Referring professional鈥檚 license number
*
Office Address
*
Office Phone Number
*
Office Fax Number
Email
(if consultation letters preferred by email)
Reason for Referral
*
Extraction
Orthognathic Surgery
Pediatrics OMFS
Pathology
Trauma
Obstructive Sleep Apnea
Implants
TMJ
Other
Procedures/Comments
Radiographs
*
With Patient
No Radiographs
Uploaded with Form Submission
Sent by Mail
Emailed to omfsreferrals.dentistry@mcgill.ca (Please ensure to include patient name in email subject followed by "x-ray," e.g. Mr. Mark Smith X-Ray)
Radiography Upload
Files must be less than
2 MB
.
Allowed file types:
gif jpg jpeg png tif
.
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