Referral Form

Please complete the details below. Fields marked * are required.

Referring To

Select the provider *

MK Dr. Mohamad H. Kadhim DDS, FRCDC Oral & Maxillofacial Pathologist

NH Dr. Natasha Holder DMD, MD, FRCDC Oral & Maxillofacial Surgeon

Patient Information

Basic contact details (email or phone required) *

Patient Name *

Patient Date of Birth *

Patient Email Address

Either patient email or patient phone is required.

Patient Phone Number

Either patient phone or patient email is required.

Primary Reasons

Check what applies

Mucosal/Cutaneous Pathology Assessment + biopsy

Extractions Surgical or simple

Third Molars Wisdom teeth

Procedure Marking

Circle the site(s) of concern

Confirm?

Draw directly on the image.

Charting

Click the relevant teeth to select them.

Selected permanent teeth: None

Selected primary teeth: None

Services

Select at least one *

Implant Pre-Prosthetic Surgery CBCT Orofacial Pain Bone Grafting Tooth Exposure TMD Other

Comments / Details

Required if “Other”

Referring Office

Referring doctor required; office contact details optional.

Referring Doctor *

Clinic Name

Clinic Phone Number

Clinic Fax Number

Referring Office Email Address

Attachments

Optional

Drag & drop files here or browse

PDF, images, DOCX, XLSX — up to 25 MB each.

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Printable PDF Available

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https://orofacialhealth.ca/referral/referralpad.pdf

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