Referrals
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Referring a Patient

Thank you for your referral — we appreciate your trust.

At Kamloops Pediatric Dentistry, we’re committed to providing compassionate, specialized dental care for infants, children, and adolescents — including those with special healthcare needs. We value collaborative relationships with our dental colleagues and strive to make the referral process simple and seamless. If you have any questions don’t hesitate to give us a call at 1-778-471-1724.

Referral Form

Complete and send the referral form by email at info@kamloopspediatricdentistry.com or fax at 1-778-471-1734.

➡️ Download Fillable PDF Referral Form

Submit a Referral Online

Pediatric Specialist Consultation Request for:

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Date of Referral (MM/DD/YY) *

Patient Name *

Date of Birth (MM/DD/YY) *

Gender at Birth (M/F) *

Parent/Guardian Name(s) *

Street Address *

City *

Postal Code *

Concerns # Email

Parent/Guardian 1 Cell # *

Parent/Guardian 2 Cell #

Other Phone

Email *

Medical Alerts and/or Allergies

Primary Dental Insurance Co

Group #

ID #

Insurance Holder

Date of Birth (MM/DD/YY)

Reason for Referral *

Consultation Only
Dental Caries
Behaviour
Pathology
Dental Trauma
Other

Other Referral Details

Radiographs *

Not Taken
Digital (Please Email)

Date of X-Ray (MM/DD/YY)

Treatment Recommended to Parents *

Behaviour Guidance with Local Anesthetic
Sedation & Local Anesthetic
General Anesthetic
None Requested/Recommended

Referring Dentist *

Phone *

Email *

Practice Address

City

Remarks/Special Concerns

Interpreter May Be Required

Yes

Patient to be returned to our office for ongoing treatment

Yes

Please keep patient at KPD for ongoing treatment

Yes

Referrals
About
Contact