562 Endodontics

Location

562 Waterloo st,
London, ON, N6B 2P9

Our Hours

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

Contact us

(519) 601- 3636

Contact Us
Contact Us

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
PRINTABLE REFERRAL FORM

Online Referral Form

Please fill out this form to refer a patient.

REFERRING DOCTOR
Dr.’s First Name *
Last Name *
Email *
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) *
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 *