Préférence linguistique : Pour le français, veuillez sélectionner Français dans le menu déroulant en haut à droite de ce formulaire.
Please provide the following information via email to info@maxillo3d.com:
1. PATIENT’S FULL NAME (Last Name and First Name)2. PRIMARY PHONE NUMBER to reach the patient AND an alternate
number3. EMAIL ADDRESS4. Name of THE HEALTHCARE PROFESSIONAL REFERRING you to the
Maxillo3D Clinic
5. REASON FOR THE REFERRAL (e.g., referral slip indicating the referring
professional’s reason)
6. Copy of the most recent DENTAL X-RAYS or other imaging
7. List of MEDICATIONS
8. Specify if you are a recipient of government assistance
We will be happy to process your request as soon as we receive this information.
You may also contact us by phone at 514-252-0880, Monday through Friday, from 8:00 a.m. to 4:00 p.m.