Referring to Our Clinic - Janeway Dental Clinic

1. Referring Dentist Info

Once you submit this form a copy will be emailed to you at the email address you provide below.

First name*

Last name*

Email address**

Name of clinic*

Tel*

Fax

Clinic address

2. Patient Info

Please fill out at least one telephone number.

Patient first name*

Patient last name*

Date of birth (month-day-year)*

MCP*

Tel(home)*

Tel (work)

Tel (mobile)

Address

City/Town

Postal code

Parent or Guardian #1 (if necessary)

Tel (work) (Parent Guardian #1)

Tel (mobile) (Parent Guardian #1 ) #1

Tel (mobile) (Parent Guardian #1) #2

Parent or Guardian #2 (if necessary)

Tel (mobile) (Parent Guardian #2 )

Tel (mobile) (Parent Guardian #2 ) #1

Tel (mobile) (Parent Guardian #2 ) #2

3. Reason for Referral*

Check all that apply

Referral Checkbox*

Medical Problem
Uncooperative
Other

Other (Reason for referral)

4. Treatment Required*

Treatment*

5. Does the patient require sedation or general anesthetic?*

Does the patient require sedation or general anesthetic?* (Radio Buttons)*

Yes
No

6. Health Questionnaire*

A.) Has the patient ever been in the hospital over night?

A.) Has the patient ever been in the hospital over night?*

Yes
No

A.) Has the patient ever been in the hospital over night? (Please Explain)*

B.) Has the patient ever had a general anesthetic or surgery?

B.) Has the patient ever had a general anesthetic or surgery?*

Yes
No

B.) Has the patient ever had a general anesthetic or surgery? (Please Explain)*

C.) Has the patient ever had any problems with an anesthetic?

C.) Has the patient ever had any problems with an anesthetic?*

Yes
No

C.) Has the patient ever had any problems with an anesthetic? (Please Explain)*

D.) Has anyone in the patient’s family or a relative ever had a problem with an anesthetic?

D.) Has anyone in the patient’s family or a relative ever had a problem with an anesthetic?*

Yes
No

D.) Has anyone in the patient’s family or a relative ever had a problem with an anesthetic? (Please Explain)*

E.) Does the patient have any allergies (including medications, food and latex)?

E.) Does the patient have any allergies (including medications, food and latex)?*

Yes
No

E.) Does the patient have any allergies (including medications, food and latex)? (Please Explain)*

F.) Is the patient taking any medications now including ibuprofen and aspirin?

F.) Is the patient taking any medications now including ibuprofen and aspirin?*

Yes
No

F.) Is the patient taking any medications now including ibuprofen and aspirin? (Please Explain)*

G.) Is the patient on any puffers for asthma?

G.) Is the patient on any puffers for asthma?*

Yes
No

G.) Is the patient on any puffers for asthma? (Please Explain)*

H.) Does the patient or anyone in their family have a bleeding disorder?

H.) Does the patient or anyone in their family have a bleeding disorder?*

Yes
No

H.) Does the patient or anyone in their family have a bleeding disorder? (Please Explain)*

I.) Has the patient had any contact with any communicable diseases, such as chicken pox or measles, in the last month?

I.) Has the patient had any contact with any communicable diseases, such as chicken pox or measles, in the last month?*

Yes
No

I.) Has the patient had any contact with any communicable diseases, such as chicken pox or measles, in the last month? (Please Explain)*

J.) Is the patient being followed by a physician for any chronic health problem?

J.) Is the patient being followed by a physician for any chronic health problem?*

Yes
No

J.) Is the patient being followed by a physician for any chronic health problem? (Please Explain)*

K.) Does the patient have any of the following conditions: (Check all that apply)

K.) Does the patient have any of the following conditions: (Check all that apply)*

K.) Does the patient have any of the following conditions: (Other)*