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Home
About
Services
Cosmetic Dentistry
Teeth Cleaning
Dental Veneers
Invisalign
Restorative Dentistry
Dental Implants
Dental Bridges
Dental Crowns
Root Canal Therapy
White Fillings
Dental Surgery
Bone & Gum Grafting
Sedation Dentistry
Wisdom Teeth Removal
Emergency Dentist
Forms
Medical History Form
Referral Form
Blog
Contact
[email protected]
416-636-6730
416 636 1436
1394 Wilson Ave Toronto, Ontario, Canada M3M 1H8
Referral Form
Toronto Smile Centre
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Introducing
*
Home
Work
2-column
E-mail
*
Date / Time
Date
Time
Please contact patient
Please contact patient
Please mark teeth/area to be treated:
2-column
Right
18
17
16
15
14
13
12
11
48
47
46
45
44
43
42
41
Left
21
22
23
24
25
26
27
28
31
32
33
34
35
36
37
38
2-column
Treatment required:
Consult Only
Root canal treatment or retreatment
Apicoectomy
Radiographs:
Forwarded
With patient
E-mail
2-column
Reason for referral:
Pulp exposed
Radiographic findings
Patient has discomfort
Prosthetic reasons
Upon completion of Endodontic Treatment Provide:
Post space
Temporary restoration
Permanent restoration
Referred by
*
Restorative treatment plan
Additional comments
Significant medical/dental history
Submit
49605
Contact Us
Toronto Smile Centre
416-636-6730
416 636 1436
[email protected]
1394 Wilson Ave Toronto, Ontario, Canada M3M 1H8
Schedule an appointment
Contact Us
416-636-6730
[email protected]
416 636 1436
1394 Wilson Ave
Toronto, Ontario, Canada,
M3M 1H8
Our Hours
Monday
8AM - 8PM
Tuesday
8AM - 8PM
Wednesday
8AM - 8PM
Thursday
8AM - 8PM
Friday
8AM - 4PM
Saturday
8AM - 4PM
Sunday
Closed
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