Dr maziar shahzad dowlatshahi

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Home
About ORIS
Services
Referral Forms
Testimonials
Gallery
Blog
Contacts

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Referral Forms

Referral Forms

Patient Name:

Date:

Tel:

Tel Work:

Referring Dentist:

Referring Dentist Phone:

Implant Services:

Sedation

Single Implant Multiple Implants Full-Arch Implants Bone Grafting Sinus Lift Immediate Placement

Periodontal Services

Reason

Gum Grafting Crown Lengthening Periodontal Disease Treatment Pocket Reduction Surgery Scaling and Root Planing Regenerative Procedures (eg. , bone regeneration) Root Coverage ProcedureItem 1

Radiographs / Attachments:

Radiographs Included (if applicable) Digital Files Sent (email to clinic [[email protected]] )

Please upload photos , if available (You can upload up to 10 files)

Note

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34- 10909 Yonge st. Richmond Hill L4C 3E3

(877) 387 6747

Fax: (289) 475 5563

[email protected]

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Preferred Day of the Week

I’m Looking for

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Preferred Time of the Day

Time

9 am - 11 am 11 am - 1 pm 1 pm - 3 pm 3 pm - 5 pm

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