Referring Dentist & Office Name* Referring Dentist Phone NumberPatient Full Name* Patient Date of Birth Parent / Caregiver Name Patient Phone NumberPatient Address Patient Email What would you like us to do after treatment?Treat and refer backTreat and continue care after adulthoodPlease send radiograph with the referral formYes, emailedYes, uploadedYes, mailedNo, not possibleEmail for radiographs - Langley: hello@smilesbyglow.ca | Richmond: richmond@smilesbyglow.caPreferred clinic location for this referred patient*AbbotsfordLangleyRichmondAdditional commentsX-ray to transfer Drop files here or Select files Max. file size: 50 MB. Please send us all the latest x-raysCommentsThis field is for validation purposes and should be left unchanged.
