Online Referral Form

Fields marked with an * are required

Referral Source

Shelter or Program Name *

Caseworker *

First and last name.

Caseworker Phone *

Caseworker Email *

Patient Information

Name *

First and last name.

Date of Birth *

Phone *

Email *

Does the patient require accessibility services?

Eligibility Questions

Is the patient currently experiencing dental pain and/ or discomfort? Does the patient have a visible defect that is tooth-related when they smile/ speak? Please explain: *

Is the patient currently experiencing pain in their back, shoulder, limbs, or jaw? Please explain: *

Does the patient struggle to get to sleep, stay asleep or feel very tired during the day? Please explain: *

Does the patient self-identify as a survivor of domestic violence? *

Yes
No

Does the patient reside in a shelter at the time of referral (or transitioned out in the past 24 months)? *

Yes
No

Are finances a barrier for the patient to access dental care, physiotherapy or other essential medical care? *

Yes
No

Does the patient have private dental insurance? *

Yes
No

Does the patient feel comfortable being treated by a male dentist? *

Yes
No

Does the patient self-identify as a member of an equity seeking group?

Indigenous
LGBTQ
Person with a disability
Visible Minority
Other
No

What is the patient's residency status? *

Temporary Resident
Applying for Permant Residency
Permanent Resident of Canada
Canadian Citizen
Other

If you are a human seeing this field, please leave it empty.

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Email Address *

First Name

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