Pmcc Referral Form

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PMCC Mouth Screening Clinic
Referral Form
nd
Dental Clinic - Room 2-931 (2
floor)
Princess Margaret Cancer Centre, 610 University Ave
Toronto, Ontario, M5G 2M9
Phone: 416-946-2198
Fax:416-946-6576
complete the info below in full (incomplete info will result in delay of appointment)
mail to address above or fax to the above number
call the PMH dental clinic if they have not called your office within one week
____________________________
Date
________________________
_________________________
Patient last name___
First name
____________________________________________
Full address
Postal code___________
______________________
___________________________
Daytime phone #
Home phone #
__________________________
____________________________
Date of birth
OHIP number
________________________________________
Referring Dentist/Physician___
DDS__MD__
________________________________________________________________
Full address
_______________________________________
__________________________
Postal code
_______________________________
_______________________________
Phone#
Fax #
_______________________________________________________
Email address (optional)
___________________________________________________________
Reason for referral
__________________________________________________________________________
__________________________________________________________________________
___________
Type of lesion:
ulcer
polyp
mass
red area
white area
other
__________________________
__________________________________
Location
Duration
_______________________________________________________________________
Size
______________________________________________________________
Medical history
___________________________________________________________________________
___________________________________________________________________________
If radiographs have been taken of the area, please send the radiographs with the patient.
For PMH office use: received___________________Office called ______________________
Appt date and time_____________________________MRN___________________________

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