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Online Referral Form

Required Fields *

Patient Contact Information
Please fill in your name.
Please fill in valid phone number.
Please fill in valid email address.
Patient's Date of Birth *
Please fill in valid year of birth.

Reasons for Referral

How does the patient pays for the dental services? *
Please select at least one option.

Referring Dentist Information

If you want to transfer digital radiographs or files please email Dr Lacombe

Please fill in dentist's name.
Please fill in valid office phone number.
Please fill in valid email address.

Radiographs Upload

Tips:

Please make sure the size of each file is lower than 2Mb.

Files will be attached in email and sent with your referral form.

Sorry, we only accept PDF, Image, Microsoft Word and Excel files. Sorry, the file size is no bigger than 2Mb.
Sorry, we only accept PDF, Image, Microsoft Word and Excel files. Sorry, the file size is no bigger than 2Mb.
Sorry, we only accept PDF, Image, Microsoft Word and Excel files. Sorry, the file size is no bigger than 2Mb.
Sorry, we only accept PDF, Image, Microsoft Word and Excel files. Sorry, the file size is no bigger than 2Mb.
Sorry, we only accept PDF, Image, Microsoft Word and Excel files. Sorry, the file size is no bigger than 2Mb.

Contact us

  • Dr. Gabriel Lacombe
  • Village Walk Family Dental
  • Suite #100, 200 Villagewalk Boulevard
  • London, ON
  • N6G 0W8
  • Phone: (226) 636-2222
  • Note: Please direct all inquiries to the anaesthesia manager, Shayma
  • Fax: (519) 681-9176
  • Email: drlacombe@lsdental.ca
  • Required fields *

    Please fill in all required fields.

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