Doctor Referral Form

Toronto Dentistry — Dr. Yolanda Cruz

1 Patient Information

First Name *

Last Name *

Email *

Phone *

Date of Birth *

Insurance

2 Referring Doctor Information

Referring Doctor Name *

Doctor Phone *

Doctor Email

Referral Date

Type of Referring Doctor *

Medical Doctor Dentist Specialty

3 Teeth / Areas to Be Evaluated

Please check teeth/areas to be evaluated

Upper Right Upper Left

Lower Right Lower Left

4 Treatments Requested

Main Treatments *

TMJ Disorder Sleep-Disordered Breathing & Snoring Mucocele Biopsy / Laser Removal Laser Dentistry CBCT CEPH Panoramic T-Scan Other

TMJ Disorder — Patient Symptoms (check all that apply)

Primary headaches or migraines Snoring/sleep apnea Disturbed, restless sleeping CPAP intolerance Daytime drowsiness Attention deficit in children Earaches, stuffiness, or ringing Neck, shoulder, back pain or stiffness Dizziness Jaw Pain or soreness in TM joints Limited mouth opening Locking jaw (opened or closed) Facial or undiagnosed teeth pain Difficulty swallowing Asymmetrical posture

5 Pain Assessment

Current Pain Level (0 = none, 10 = worst)

No painModerateWorst possible

6 Reason for Referral

Reason for Referral *

7 Radiographs & Images

Upload Radiographs, X-rays, or Photos

📎

Click to upload or drag files here

Accepted: JPEG, PNG, PDF, DICOM — Max 10 MB per file, up to 5 files

8 Additional Comments

Comments / Remarks

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This form is submitted securely. A copy will be sent to the referring doctor's email if provided.

✓

Referral Submitted Successfully

Thank you. Dr. Cruz's office will review the referral and contact the patient to schedule an appointment. A confirmation has been sent to the referring doctor's email.