Our Hours

Mon, Tues, Thurs and Fri 8:30 am to 5:00 pm
Wed : 8:30 am to 4:00 pm

Referrals

Thanks for entrusting us with your patients' endodontic needs.

At 562 endodontics, we understand how important it is to ensure the highest quality of care, and your referral means a lot to us. Rest assured that we will take great care in providing the best possible service for your patient.

Online Referral Form

Please fill out this form to refer a patient.

You will receive a copy of the referral form via email for your records after submission.

Preferred doctor for appointment scheduling

Dr. Jacqueline Lopez Gross, DDS, MSc, FRCD (C)

Dr. Manfred Friedman, B.D.S (Wits.) B.Ch.D Hons (Pret)

Dr. R. Gregory Carr, DDS

Dr.’s First Name *

Email *

Last Name *

Office Phone Number *

Office Name *

PATIENT INFORMATION

First Name *

Last Name *

Patient Email

Preferred Phone number *

Home Phone

Date of Birth *

REFERRED FOR

Tooth Number (Separate with comma) *

Consult Only

Consult and Treatment as Needed

Emergency Appointment

Please upload any patient files or x-rays here:

**Please send the most recent periapical and bitewing if available.

Add your File here

Maximum file size: 10 MB

Tooth Status (select an option) *

Restorative Treatment Planned (select an option) *

Restoration After Treatment (select an option) *

We will restore with Fuji to keep as a base for the composite core unless you prefer:

restoration after treatment *

INSURANCE INFORMATION

Company *

Member ID/Certificate ID #

Group #/Policy #

Policy Holder

Policy Holder: Date of Birth

Policy Holder Address

SPECIAL ACCOMMODATION

(Relevant Medical Condition, Accommodation, Dental Anxiety, Urgent Matter, Staff Member, Doctor’s Relative, etc.)

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TERMS & CONDITIONS *

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Referrals

Thanks for entrusting us with your patients' endodontic needs.

Online Referral Form

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