Referring Doctors Form

Thank you for your confidence in referring your patients to SmileNow Calgary. Please complete this form to help us provide the best possible care.

Patient Information
Referring Doctor
Procedure(s) or Consultations Requested
Area of Treatment

Select the teeth that require implants (click the checkboxes below the tooth numbers):

Upper Teeth

18
17
16
15
14
13
12
11
21
22
23
24
25
26
27
28

Lower Teeth

48
47
46
45
44
43
42
41
31
32
33
34
35
36
37
38
Dental Implants
Additional Notes
X-Rays and Patient Photos

Upload X-Rays & Photos

Drag & drop files here or

Maximum 10 images, 2MB per file (JPG, PNG, WEBP)