Referring Patients to Fourth Ave Endodontics

Referring Offices Form

Fill out our referring office request form below or download it here to print it out.

01Patient Information

Preferred Name

Please enter a valid preferred name.

Last Name

Please enter a valid last name.

Telephone Number

Please enter a valid telephone number.

Referring Doctor (if applicable)

Referring Dentist Name

Referring Dentist Telephone

02Dental Information

Tooth Details

Tooth Number

Tooth Location (ex. Top Left)

Services Requested

Treatment Requests

Leave post space

Restore access temporarily

Restore access permanently

Please provide any recent radiographs or other images taken of the patient in the area of clinical interest.

03Additional Remarks

_{* Appointment time is reserved for you. Please be aware that 48 hour notice is
required to reschedule your appointment to avoid a cancellation fee. All appointments must be
confirmed.}

Address

Suite 237 - 1338 Fourth Ave, St. Catharines

Phone

Tel: (289) 362 - 2980

Fax: (289) 362 - 3382

E-mail

info@fourthaveendodontics.com

Hours

Monday - Friday: 8am - 5pm

Payment Options

Your consultation appointment will provide you with a predetermination outlining the costs of your upcoming treatment. Payment will be due at the time service is rendered. We accept Visa, Mastercard, Debit, American Express or cash payments. If you have insurance coverage, we can assist you in submitting your claim electronically or provide you with the forms necessary for you to submit independently.

Referral Form