Online Referral

Online Form - For Dental Professionals Only*

*for patients wanting to book an appointment, please have your dentist send a referral to our office.

 

 

Referring Dentist:*

Dentist Email:

Address

Phone Number

Examination requested for:

Radiographs

Indicate area(s) of concern:*

Patient Name:*

Telephone Number:

Date of Birth:

Date:

Upload File

Feel free to use our downloadable referral form for Vancouver or for Dr. Han’s satellite office in Abbotsford.