Online referral Use our secure online form to refer your patients. It's simple, easy and quick! If you prefer, you can email us at clinique@parogatineau.ca. Person responsible for the protection of personal information: Julie Hayes 819-525-9255 PATIENT * = required fields First name* Last name* Date of birth Day01020304050607080910111213141516171819202122232425262728293031 MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year2023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921 Patient's phone (home)* Patient's phone (mobile) Patient's email Choice of communication* Please contact the patientThe patient will contact you Mode de communication préféré* EmailPhone Choix du spécialiste Dr Georges JammalDr Houda LallaliDre Isabelle Quenneville1st available specialist REFERRING DENTIST Referring dentist* Dental clinic* Referent's email A confirmation email will be sent to this address CARE REQUIRED Generalized periodontal diseaseLocalized periodontal diseasePeriodontal assessment prior to orthodontic treatmentGum graft / recessionFrenectomyGingivectomy / gingivoplastyImplantPeri-implantitis treatmentExtraction and bone graftAesthetic correctionCrown lengthening procedurePathology / biopsy3D imagery (CBCT) - Specific region3D imagery (CBCT) - Maxillary arch3D imagery (CBCT) - Mandibular arch3D imagery (CBCT) - Two arches Right 1817161514131211555453525185848382814847464544434241 Left 2122232425262728616263646571727374753132333435363738 COMMENTS & ADDITIONAL INFORMATION Other Please take x-rayX-ray given to the patientX-ray sent by mail Attach files (relevant x-ray or other)
