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ORAL & MAXILLOFACIAL URGERY - Aspen Oral Surgery · Oral&MaxillofacialSurgeon...

Date post: 11-Aug-2020
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Conveniently located in the Palermo Professional Centre at the South-East corner of Dundas and Old Bronte Road. The parking is free. 1. Pertinent x-rays 2. Any insurance information 3. Your list of medications 4. This referral slip 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 day services are rendered. We do not accept insurance payments directly. Kindly notify us by phone at least 48 hours prior if you are unable to keep your appointment. We do not accept cancellations via e-mail. Oakville Trafalgar Memorial Hospital 40 7 25 38 5 N 407 Dundas St. W Upper Middle Rd W Bronte Rd Old Bronte Rd Third Line 403 T (905) 582-2188 F (905) 582-9886 [email protected] 2525 Old Bronte Road, Suite 280 Oakville, ON L6M 4J2 www.aspenoralsurgery.ca PLEASE CALL (905) 582-2188 TO SCHEDULE YOUR APPOINTMENT AND BRING THE FOLLOWING ITEMS A SPEN O RAL & MAXILLOFACIAL S URGERY For online referral, scan this code with your mobile phone @ASPENORALSURGERY @ASPENORALSURGERY
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Page 1: ORAL & MAXILLOFACIAL URGERY - Aspen Oral Surgery · Oral&MaxillofacialSurgeon DR.DEEPIKACHUGHBSc,DDS,M.Sc,FRCD(C) OralPathologist DECIDUOUS TEETH Pleaseprovidereportby: Sendmemorereferralpads

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

[email protected]

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

Page 2: ORAL & MAXILLOFACIAL URGERY - Aspen Oral Surgery · Oral&MaxillofacialSurgeon DR.DEEPIKACHUGHBSc,DDS,M.Sc,FRCD(C) OralPathologist DECIDUOUS TEETH Pleaseprovidereportby: Sendmemorereferralpads

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

[email protected]

2525 Old Bronte Road, Suite 280Oakvi l le, ON L6M 4J2www.aspenoralsurgery.ca


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