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(902) 576-3070
37 Ella Lane, Unit 100, Bedford, NS B4B 2J6
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Patient Referral Form
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Please select a doctor:
Dr. Matthew Brown
Dr. Richard Bezanson
No Preference
Patient's Last Name
Patient's First Name
Date of Birth
Age
Telephone Number
Mobile Number
Email
Address
Is this for a child?
No
Yes
Parent/Guardian
Dental Insurance
Insurance Company Name:
Plan Holder Name:
Insurance Policy/Group #:
Insurance Certificate/ID #:
Relationship to Plan Holder:
Self
Spouse
Common Law Dependent
Insurance Plan Holder’s D.O.B:
Employer of Plan Holder:
Referring dentist:
Office email:
Phone:
Fax:
Reason for referral:
Medical & Dental History or Medications of Note:
Please schedule Patient:
ASAP
Elective
I would prefer your Orthodontic Diagnosis and treatment plan sent to me:
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37 Ella Lane, Unit 100, Bedford, NS B4B 2J6
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