Doctor Referral

We look forward to the opportunity to provide care for your patients. Physicians and dentists may use the form below to connect with us. Please note, dentists referring for Oral Appliance Therapy for Obstructive Sleep Apnea are requested to ensure that their patients have had a sleep study.

Download PDF Version of Form

Referral Form

Patient Name:(Required)

Patient Number:

Patient DOB (M/D/Y)(Required)

Patient Email:(Required)

Referring Doctor:(Required)

Doctor Number:

Current Date(Required)

Reason for Referral:(Required)

Oral Appliance Therapy for Medically Diagnosed Snoring and Sleep Apnea

HealthStart/Myofunctional Appliance

Invisalign Palatal Expander and Invisalign Mixed Dentition (Invisalign First)

Invisalign Teen/Adult

Cosmetic Flowable Bonding

Additional Notes:

Contact Us

Dr. Hania and her team is dedicated to ensuring that you receive the best care and attention. Please use the form below to reach out to us.

(613) 680 2888

613-680-2890

1390 Clyde Ave. Unit 102, Ottawa, ON K2G 3H9

info@clydedentalcentre.ca

Opening Hours:

Mon-Thurs : 8:00 am - 4:30 pm

Fri-Sun : Closed