Canadian Dental Association Standard Dental Referral Form

To submit this form, please ensure all fields are accurately filled out. You can email the completed form to the referral office. Alternatively, the form can be faxed to the provided number. If the office accepts online submissions, upload the PDF via their online submission portal. For a physical copy, you may mail the form to the office address. Always double-check for any specific instructions provided by the referring office. Our advice: Keep a copy of the completed form for your records and confirm receipt with the referral office.

Important submission dates for this form in 2024 and 2025 include the patient's referral appointment and follow-up consultation dates.

The purpose of the Canadian Dental Association Standard Dental Referral Form is to provide a standardized, comprehensive document for referring patients from one dental professional to another. Ensuring that all necessary patient information, including medical and dental history, reason for referral, and any specific treatment requests, is clearly communicated helps facilitate appropriate patient care. The form also ensures continuity of care by including fields for follow-up, reporting, and any relevant history. This thorough approach aids in providing the best possible patient outcomes and coordinated dental care.

• 1. From: The name and contact details of the referring dental professional.
• 2. To: The name and contact details of the receiving dental professional.
• 3. Patient: The patient's name and personal details including birthdate and address.
• 4. Parent/Guardian: Details of the patient's parent or guardian, if applicable.
• 5. Telephone: Contact telephone numbers for the patient and/or guardian.
• 6. Reason for Referral: Detailed reasons for the referral, including areas of concern.
• 7. Consultation: Specific areas for consultation and evaluation.
• 8. Treatment: Specific treatment requested by the referring dental professional.
• 9. Relevant History: Details of any relevant dental or medical history, including allergies and specific medical problems.
• 10. Radiographs: Information about enclosed radiographs and request for their return after use.
• 11. Notification and Reporting: Details on notifying the referring professional upon completion and modes of reporting.
• 12. Post-referral Maintenance: Instructions for any post-referral maintenance required.
• 13. Other Records: Information on availability and handling of other records related to the patient.
• 14. Signature: Signature of the referring dental professional.
• 15. Date: Date when the form was filled out and signed.

Failure to submit this form can lead to miscommunications and delays in patient care. This might ultimately impact the patient's treatment process.

• Miscommunication: Incomplete or missing forms can lead to misunderstandings between dental professionals.
• Delays in Treatment: Lack of proper referral can delay the initiation of necessary treatments.
• Inadequate Patient Care: Without a referral form, essential medical and dental history might be missed, leading to inadequate patient care.
• Legal Issues: Failure to provide proper documentation can lead to legal disputes regarding patient treatment.

• 1. Specialist Referral: When referring a patient to a dental specialist for further treatment or evaluation.
• 2. Consultation: When a second opinion or consultation is required for a patient's dental condition.
• 3. Treatment Transfer: When transferring a patient's ongoing treatment to another dental professional.
• 4. Insurance Documentation: Providing detailed reasons for referral and treatment to satisfy insurance requirements.
• 5. Legal Documentation: Ensuring proper documentation for any legal matters related to the patient's dental care.