PROCEDURES
MEET THE TEAM
OUR FACILITIES
REFER A PATIENT OR YOURSELF

Refer A PatientAndy Jackson2026-01-06T11:35:35-08:00

REFER A PATIENT OR YOURSELF

Please note that we only accept patient referrals from doctors.

If you are a patient requesting a referral on behalf of yourself, please see your doctor before filling out this form. Contact us at [email protected]

Download Printable Form

Or fill out the online form below

Please enable JavaScript in your browser to complete this form.

I am a doctor referring a patient: *

Specializing In: *

Endodontic Therapy
Periodontal Therapy and Implant Dentistry
Prosthodontics

Are you interested in prosthodontic treatment? *

Prosthodontic care includes crowns, bridges, dentures, dental implants, and replacement or rebuilding of teeth.

For all other dental treatments, a referral from your general dentist or dental specialist is required.

Patient Contact Info

First Name *

Last Name *

Date of Birth *

Medical Alert *

Patient Contact Info

First Name *

Last Name *

Date of Birth *

Medical Alert *

Address *

City *

Province *

Postal Code *

Home Phone *

Cell Phone *

Email *

Referred by Dr. *

Doctor's Phone *

Address *

City *

Province *

Postal Code *

Home Phone *

Cell Phone *

Email *

Dentist's Phone

Specialising in Endodontic Therapy

X-rays enclosed: *

Yes
No
Emailed

Exo if RCT unrestorable? *

RCT Final Filling? *

Upload X-rays

Drag & Drop Files, Choose Files to Upload You can upload up to 20 files.

Relevant Information *

Specialized Periodontal Therapy and Implant Dentistry

X-rays enclosed: *

Yes
No
Emailed

Periodontal Therapy: *

Periodontal Treatment
Implant Treatment
Gingival Grafting
Crown Lengthening
IV Sedation
Other

Upload X-rays

Drag & Drop Files, Choose Files to Upload You can upload up to 20 files.

Remarks

Fixed & Removable Prosthodontics

X-rays enclosed: *

Yes
No
Emailed

Upload X-rays

Drag & Drop Files, Choose Files to Upload You can upload up to 20 files.

Remarks

First Layout Dental

How can we help you?

Please send us a referral pad *

Please send us a referral pad

Primary Dental Insurance

Insured:

Carrier:

Employer:

Group/Policy #:

ID or SIN:

Division:

Department #:

Date of Birth:

Secondary Dental Insurance

Insured:

Carrier:

Employer:

Group/Policy #:

ID or SIN:

Division:

Department #:

Date of Birth:

Contact Us

#105 - 389 12th Street Courtenay, B.C V9N 8V7

Phone: (250) 871-8277

Email: [email protected]