Online Referral Form

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Online Referral Form

Dear colleague, I will no longer accept adult patients with government sponsored programs (ODSP, OW, NIHB), unless they were already treated by me before. Thank you for your cooperation.

Required Fields *

Patient Contact Information

Patient's Name *

Please fill in your name.

Parent or Guardian

Address

Daytime Phone Number the patient may by reached at *

Please fill in valid phone number.

Business or Cell phone number

Email Address*

Please fill in valid email address.

Patient's Date of Birth *

Month

Day

Year

Please fill in valid year of birth.

Reasons for Referral

Mentally and /or physically challenged patient

Needle phobic

Need sedation for extensive dental treatment

Have a high gag reflex

Have had traumatic experiences

Difficulty getting numb

Uncooperative paediatric patient

Please provide a brief treatment plan

How does the patient pays for the dental services? *

Please select at least one option.

ODSP

Healthy Smiles Ontario

First Nation

Private Insurance

Referring Dentist Information

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

Name of Referring Dentist*

Please fill in dentist's name.

Contact Person

Office Phone Number*

Please fill in valid office phone number.

Office Fax Number

Email Address*

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.

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

Please upload radiograph 02 Sorry, we only accept PDF, Image, Microsoft Word and Excel files. Sorry, the file size is no bigger than 2Mb.

Please upload radiograph 03 Sorry, we only accept PDF, Image, Microsoft Word and Excel files. Sorry, the file size is no bigger than 2Mb.

Please upload radiograph 04 Sorry, we only accept PDF, Image, Microsoft Word and Excel files. Sorry, the file size is no bigger than 2Mb.

Please upload radiograph 05 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