Name: EJC Dentistry
Address: 118 Stinson St, Hamilton, ON, L8N 1S5, CA
Telephone: (905) 522-1188

Refer a Patient

To refer a patient, please fill out the referral form below.

We are thankful for your referrals and we will refer the patient back to you for future dental needs. A follow-up letter with be sent with details about the success of their treatment. Thank you for trusting us with the care of your patients. - The EJC Dentistry Team

Call (905) 522-1188

Patient Information

Patient's First Name

Patient's Last Name

Date of Birth

City

Phone Number

Dentist Information

First Name

Last Name

Email Address

Your email address will be used to send you a confirmation of receipt and/or consultation report.

Phone Number

What service are you referring the patient for?

Additional Information

Provide additional details if possible.

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*To share additional patient files, please call our office for more information.

Refer a Patient

Patient Information

Dentist Information

Additional Information

We Look Forward to Your Smile