Pediatric Referral Form

Referrer Information

Patient Information

Insurance Information

Referral Details

Note: Please advise patients that the consultation fee is $239 and fees will apply for any radiographs needed.

Paediatric Dentists have a specialist's fee guide. Fees are higher than the GP fee guide. Due to this, please inform the parents that although they may have 100% coverage with their insurance, most insurances do not cover the full specialist fee. Typically, insurances will only cover up until the GP fee, and the difference would be paid out of pocket. Furthermore, at this time, we are limited to nitrous oxide as our only form of sedation. Due to high demand, we unfortunately have to limit patients whose only coverage is through Healthy Smiles Ontario. However, please have parents apply for CDCP and we will take them – no limit.

Please feel free to reach out with any questions or concerns. We look forward to working with your referrals!