Desert Hills Dental Clinic is Open 7 Days a Week

Home
Services
Our Services
Emergency Dental Care Clear Aligner Braces
Cosmetic Dentistry Dental Cleanings Dentures
Restorative Dentistry Sedation Dentistry Tooth Extractions
Patient Information
About Us
About Desert Hills Dental Our Team Direct Billing & Insurance News
Referral Form
Contact Us

Referral

Please submit your referral using the form below. If you'd prefer to download the PDF you can do so By Clicking Here. Please email completed PDF's to info@deserthillsdental.ca

Desert Hills Dental Medical Form Referral

Dr. Jaspal Sarao B.D.S.D.M.D

Dr. Sunil Malhotra B.D.S.D.D.S

Referral

Referring Doctor

Date

Patient's First Name

Patient's Last Name

Date of Birth

Address

Address Line 1

Address Line 2

City

Postal Code

Parent / Guardian

Phone

Cell

Medical Concerns

Consultation Regarding

Extraction

Implants

Sedation

CBCT

Full Arch

Upper Arch

Lower Arch

Other

Special Instructions

Please call patient

Patient will call you

X-rays emailed

Please take X-rays

Insurance Information

Name of Insured

Date of Birth

Carrier

Policy

Dr. Email Address

Dr. Phone Number

"Caring, Calming, Modern Dentistry."

Pages

Home About Us Patient Information Direct Billing & Insurance Our Team News Contact Us

Services

Emergency Dental Care Clear Aligner Braces Cosmetic Dentistry Dental Cleanings Dentures Restorative Dentistry Sedation Dentistry Tooth Extractions

Get in Touch

Referral Form Phone: (250) 372 8578 Email: info@deserthillsdental.ca 251-1320 Trans-Canada Highway Kamloops BC, V1S1J2 Click for Directions Privacy Policy

Website by Kamloops Web Design Inc.

(250) 372 8578

Book Now