Date of Submission
/
Day
/
Month
Year
Date
Oral Surgery
Select a Clinic Location
*
Toronto- 1940 Eglinton Ave.E. Suite 500, M1L 4R1
Richmond Hill - 9350 Yonge Street Suite 206, L4C 5G
Aurora - 236 Wellington St.E. Suite 200, L4H 1J5
No Location Preference
Mount Sinai Hospital (Dr. Brian Rittenberg & Dr. Maria Franco only)
Mount Sinai Hospital - 600 University Avenue Suite 412, Toronto, Ontario, M5G 1X5
Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery
Dr. Eddie Reinish
Dr. Brian Rittenberg
Dr. Peter Gioulos
Dr. Amir Mousavifar
Dr. Kristopher Lee
Dr. Oscar Dalmao
Dr. Ross Linker
Dr. Maria Franco
Dr. Amina Bouzid
Any Surgeon
Oral Surgeons at Mount Sinai Hospital
Dr. Brian Rittenberg
Dr. Maria Franco
Oral Medicine & Pathology
Oral Medicine & Pathology
Dr. Riva Black
Dr. Iona Leong
Oro-facial Pain
Dr. Priya Jayaraman
Oral Radiology/CBCT
Dr. Ernie Lam
X rays / Clinical Images
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I will upload X rays or clinical images
X-rays or clinical images not available
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
/
Day
/
Month
Year
Date
Cell Phone
*
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Address
*
Unit/Apt
City
Postal Code
Province
Referring Doctor Information
Referred by
*
First Name
Last Name
Referrer's phone number
*
Referring Doctor's Phone
Format: (000) 000-0000.
Referrer's email address
*
example@example.com
Clinic Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Tooth or investigations required
Procedure/Treatment needed
*
Extractions
Exposure & Bond
Dental Implants
Corrective Jaw Surgery
TMJ Disorders
Oro-facial pain
Pathology
Radiology & Imaging
Other
Adult or Primary Teeth
Adult
Primary
Upper Right Adult
Rows
8
7
6
5
4
3
2
1
Tooth
Upper Left Adult
Rows
1
2
3
4
5
6
7
8
Tooth
RIGHT
LEFT
Lower Right Adult
Rows
8
7
6
5
4
3
2
1
Tooth
Lower Left Adult
Rows
1
2
3
4
5
6
7
8
Tooth
Upper Right Primary
Rows
E
D
C
B
A
Tooth
Upper Left Primary
Rows
A
B
C
D
E
Tooth
RIGHT
LEFT
Lower Right Primary
Rows
E
D
C
B
A
Tooth
Lower Left Primary
Rows
A
B
C
D
E
Tooth
Additional Information/Details
For 3D Imaging/CBCT please fill out the instructions on page 3.
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Radiology & 3d imaging
X-rays or images 1
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Radiology Request
Please use the odontogram on page 2 as needed to specify your CBCT area, or describe in the comments box below.
Please note that the odontogram above will be used to specify your CBCT requirements
PAN
CEPH
CBCT
Specific Investigation
Implant planning
Impacted Teeth
TMJ
Radiologic Pathology
RADIOLOGY COMMENTS
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