Dentistry Surgical Care Unit (DSCU) Referral Form

FOR PAEDIATRIC PATIENTS ONLY REQUIRING GENERAL ANAESTHESIA FOR DENTAL TREATMENT

Fields denoted by an asterisk (*) are required.

Referring Source (Dentist, Physician, Public Health, Community Agency)
Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Phone Phone - ### - ### ####
Patient Information
Patient's Name Patient's Name First Last
Patient's Date of Birth Patient's Date of Birth / MM / DD YYYY
Patient Gender

Patient Gender Male Female Undefined
Parent/Guardian
Patient's Address Patient's Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Patient's Email
Patient's Phone Patient's Phone - ### - ### ####
Patient’s Specific Medical Conditions
Patient’s General Medical Condition
Reason for Patient Referral

Please be specific, provide tooth numbers and forward dated x-rays using the link below
NOTE: Following completion of any dental work, all patients will be returned to the referring dentist/clinic for ongoing care
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 Children’s Dental Clinic
Upload X-Rays/Documents

Attach Files
Please select one or more of the following

Please select one or more of the following HSO (Healthy Smiles Ontario) CDCP (Canadian Dental Care Plan) NIHB (First Nations / Inuit) Private Insurance No Insurance