Convenient ly located in the Palermo Professional Centreat the South-East corner of Dundas and Old Bronte Road.The parking is free.
1. Pert inent x-rays
2. Any insurance information
3. Your l ist of medicat ions
4. This referral s l ip
5. Your health card
6. Patients under the age of 18 must be accompanied by a
parent or legal guardian
Please be advised that payment is due the same dayservices are rendered. We do not accept insurancepayments directly.
Kindly noti fy us by phone at least 48 hours prior i f you areunable to keep your appointment. We do not acceptcancel lat ions via e-mai l .
Oakvil leTrafalgarMemorialHospital
407
25
38
5
N
407
DundasSt.W
Upper
MiddleRd
W
Bronte Rd
Old Bronte Rd
Third Line
403
T (905) 582-2188F (905) 582-9886
2525 Old Bronte Road, Suite 280Oakvi l le, ON L6M 4J2www.aspenoralsurgery.ca
PLEASE CALL (905) 582-2188 TO SCHEDULE YOURAPPOINTMENT AND BRING THE FOLLOWING ITEMS
ASPENORAL & MAXILLOFACIALSURGERY
For online referral, scan thiscode with your mobile phone
@ASPENORALSURGERY @ASPENORALSURGERY
ASPEN ORAL & MAXILLOFACIAL SURGERY
WISDOM TEETH REMOVALTreat or prevent common
complications associated withretained third molars
EXPOSURE OF TEETHIn conjunction with your orthodontic
treatments
DENTAL IMPLANTSOur goal is to simplify your care
BONE GRAFTINGReconstruct your jaw bone inpreparation for dental implants
ORTHOGNATHIC SURGERYCorrect the alignment of your jaws
and improve your bite
Aspen Oral & Maxillofacial Surgery is dedicated to delivering expert oraland maxillofacial surgical care in our state of the art facility. Dr. Cloutier,Dr. Chugh, Dr. Turgeon, our anesthesiologists and the entire team strivecontinuously to offer their patients unparalleled care and compassion.
SERVICES PROVIDED
SLEEP APNEA & SNORINGOral appliances and surgical
procedures are available to improveyour sleep
PATHOLOGY & INFECTIONTreat cysts, benign tumors,
infections or other jaw pathologies
COSMETIC LIP FILLERSJuvederm PlusTM and VolbellaTM
CBCT IMAGING3D digital scan allows accurate
diagnosis
IV SEDATION AND GENERALANESTHESIA
Your comfort is our first priority
CBCT REFERRAL FORM
MeasurementsVirtual implant placement
Reg ion o f I n t e r e s t :
Re f e r r a l De t a i l s :
Please provide report with:
Dental Implants
Pre-prosthet ic
Soft Tissue Graft
Hard Tissue Graft
Frenectomy
REASON FOR REFERRAL
Patient Name:
Pat ient Tel :
Pat ient Cel l :
DOB:
Extract ions
Infect ion
Pathology
Apicoectomy
Trauma
Sinus Augmentat ion
Exposure / Bonding
Orthognathic Surgery
IV Sedation / GA
CBCT only ( f i l l CBCTreferral form)
Referred by:
Referral Tel :
Referral Emai l :
Referral Date:
Comment s:
E-mai led to [email protected] with patient Take X-rayMai led
E -ma i lMai l
Cal l meFax
DR. MARTIN CLOUTIER DMD, MSc, FRCD(C), Dipl. ABOMSOral & Maxillofacial Surgeon
DR. DEEPIKA CHUGH BSc, DDS, M.Sc, FRCD(C)Oral Pathologist
DECIDUOUS
TEETH
Please provide report by:
Send me more referral pads
X-Rays:
ASPENORAL & MAXILLOFACIALSURGERY
T (905) 582-2188F (905) 582-9886
2525 Old Bronte Road, Suite 280Oakvi l le, ON L6M 4J2www.aspenoralsurgery.ca