For dental offices

Refer a patient

For dental offices referring a patient to Dr. Rafael Bustamante, a general dentist whose practice focuses on root canal therapy and aesthetic restoration with the Bioclear Method. Fill in the form below, or call us at (780) 482-3636.

Fields marked * are required.

Patient

Patient name

Date of birth

Home phone

Cell

Address

City

Province

Postal code

Please give a phone number or an email for the patient.

Referring office

Referred by Dentist and office name.

Phone

EmailUsed as the reply address.

Please give a phone number or an email for your office.

Reason for referral

Tooth #Tap the teeth on the chart or type the numbers, for example 36, 37. FDI numbering.

Appointment date

Time

Referred regarding ConsultationRoot canal therapyRetreatment of RCT (including post/file removal)Surgical endodontics

Restoration required

Choose any that applyCompositePost spaceIRMCavit

Additional information

NotesFor example prophylactic antibiotics or anxiety.

Insurance

Optional. You can leave this blank and the patient can bring their insurance details.

Primary

Policy holder

Date of birth

Insurance co.

Gr./Plan/Pol. #

ID/Cert. #

Secondary

Policy holder

Date of birth

Insurance co.

Gr./Plan/Pol. #

ID/Cert. #

Send more referral forms

Please send only the details we need. You can leave out insurance numbers and give them to us by phone at (780) 482-3636.