Student Clinical Affairs Office Referral Form

Fields denoted by an asterisk (*) are required.

Patient Type

Patient Type Adult Paediatric
PLEASE NOTE: At this time we ARE NOT accepting patients more than a 60 kilometre drive to the school. Restoring missing ANTERIOR teeth via implant supported restorations, and implant supported CUDs, are not treatments accepted by the Student Dental Clinic.
Patient Information
Patient's Name Patient's Name First Last
Patient's Date of Birth Patient's Date of Birth / MM / DD YYYY
Parent/Guardian Name Parent/Guardian Name First Last
Admin Review - Suitable

Admin Review - Suitable Yes No Investigating
Reviewer's Decision

Reviewer's Decision Yes No Investigating Grad Ortho Paediatric
Admin Review Comments
Form Uploaded to Salud Form Uploaded to Salud / MM / DD YYYY
Complete

Complete NEW WAITLISTED ASSIGNED NOT SUITABLE NOT INTERESTED UNABLE TO CONTACT FRONT DESK TO SCHEDULE COMPLETE
Completion Date Completion Date / MM / DD YYYY
Letter required?

Letter required? Yes No Letter Complete
Follow-up Required?

Follow-up Required? Yes No Follow-up complete
Waitlist
Reviewer's Name
Reviewer's Comments:
Patient's Chart Number
Patient's Phone Patient's Phone - ### - ### ####
Patient's Address Patient's Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Patient's Email
Patient's Alternative Phone Patient's Alternative Phone - ### - ### ####
Patient’s General Medical Condition
Reason for Patient Referral

Please be very specific, provide tooth numbers and forward x-rays
Limited or Comprehensive Treatment (choose one)

Limited or Comprehensive Treatment (choose one) Limited Treatment - Returning to referring dentist once treatment completed Comprehensive Treatment - Patient to remain as a patient of Schulich Dental Clinic
If this is for limited endo treatment do you wish the final restoration of amalgam/composite to be completed at the school?

If this is for limited endo treatment do you wish the final restoration of amalgam/composite to be completed at the school? Yes No
If applicable would you like a crown or onlay to be placed?

If applicable would you like a crown or onlay to be placed? Yes No
Treatment Plan Changes (choose one):
If the dental school’s treatment plan changes from your specific request, do you wish to be contacted before we proceed with any treatment

Treatment Plan Changes (choose one):
If the dental school’s treatment plan changes from your specific request, do you wish to be contacted before we proceed with any treatment Yes No
X-Rays or other additional information (choose one):

X-Rays or other additional information (choose one): Yes No (will send via email to dental.clinics@schulich.uwo.ca) None available
Upload X-Rays

Select FilesSelect Files

Attach Files
Referring Dentist Information
Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Phone Phone - ### - ### ####
Fax Fax - ### - ### ####
By clicking the button below you are confirming you are the referring dentist:

By clicking the button below you are confirming you are the referring dentist: I agree

Student Clinical Affairs Office Referral Form

Student Clinical Affairs Office Referral Form

PLEASE NOTE: At this time we ARE NOT accepting patients more than a 60 kilometre drive to the school. Restoring missing ANTERIOR teeth via implant supported restorations, and implant supported CUDs, are not treatments accepted by the Student Dental Clinic.

Patient Information

Referring Dentist Information