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Upload your X-rays/Forms

Upload File

Name of patient

Date of X-ray

FILL OUT THE REFERRAL FORM

Kenedy Ruth Dental Centre in Brampton offers prompt dental treatment for people of all ages. Please use the referral form below. If you have any questions, contact us.

 

PATIENT REFERRAL FORM

Patient name

Date

Female/Male

Phone number

Date of birth

I am referring our patient for the following symptoms (please check all that apply):

I am specifically concerned about the following condition(s)

Panoramic Radiography Attachment

Date of the Panoramic Radiography

Doctor

Upload File

Date​

Phone number

Fax

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