Doctor Referral

Huronia Maxillofacial Radiology
C. Grace Petrikowski DDS, MSc, FRCD(c)
Oral and Maxillofacial Radiologist

Referral for Diagnostic Imaging

Patient:

D.O.B.:

Email:

Telephone:

Appt. date & time:

Approx. fee:

Parent’s Name (if minor):

Indicate exact tooth number(s):

Selected tooth number(s):

Instructions and patient history

Referred by Doctor

Doctor’s Email

Date

1867 Yonge Street, Suite 602
Toronto, Ontario M4S 1Y5
T 416.440.3892 F 416.440.3931

E info@hmfr.ca

4 Checkley Street, Suite 300
Barrie, Ontario L4N 1W1
T 705.735.4442 F 705.735.4404