Dr. Kirsty Large Referral Form

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Please email radiographs to Hello@drlarge.ca

Provision of Dental Treatment under Sedation & General Anesthesia for Pediatric Patients

Dr. Kirsty Large, D.M.D. General Dentist 1500 Bank Street - Suite 102, Ottawa, Ontario K1H 7Z2 Tel: 613-818-1622 Fax: 613-739-7479

Date / Time

Tel:

Date Of Birth /

Telephone: Home / Maison:

Email / Courriel:

Referred by / référé par

Patients Name

Address

Telephone: Cell

Name Of Parent / Nom du parent:

Reason for Referral / Raison de la référence

Treatment Requested / Traitement requis:

Relevant Medical History / Antécédents médicaux

Radiographs / Radiographies

Enclosed / Ci-incluses

Emailed / Courriel

Given to Patient / Avec le patient

Appointment / Rendez-vous:

A written report will be sent to your office once the treatment has been completed.

Un rapport écrit sera envoyé à votre bureau une fois le traitement terminé.

Comment

New To The Clinic ?

Blue Heron Dental Group is built on a strong reputation of over 30 years of service to the Ottawa community and the families who live here. Other dentists in the community refer pediatric patients to our clinic due to our experience and reputation when treating children.

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Contact Us

102-1500 Bank street Ottawa, Ontario K1H 7Z2

613-706-4101

Info@blueherondentalgroup.ca

Clinic Hours

Mon: 7:30am - 3:30pm
Tue: 7:30am - 3:30pm
Wed: 7:30am - 3:30pm
Thu: 7:30am - 7:30pm
Fri: 7:30am - 3:00pm

Sat: Closed
Sun: Closed