Refer a Patient Quickly and easily refer patients to Medicine Hat Pediatric Dentistry Our online referral form sends your patient’s information directly to us. It uses secure privacy protection and gives you the option to attach any supporting records. Fill out the online form or download our Referral form PDF. We will contact your patient ASAP to schedule an appointment. Thank you! Referring Doctor InformationDoctor First Name *Doctor Last Name *Clinic Phone Number *Clinic Email Address *Clinic AddressAddress Line 1 *Address Line 2City *Province *Postal Code *Country *Patient Contact InformationPatient First Name *Patient Last Name *Patient Date of Birth *Parent/Guardian First Name *Parent/Guardian Last Name *Parent/Guardian Date of Birth *Patient Phone Number *Patient Email Address *Address Line 1 *Address Line 2City *Province *Postal Code *Country *Insurance InformationInsurance Type *Private InsuranceADSCNo InsuranceNIHBOtherIf other, please explain:Insurance ProviderPolicy HolderGroup/Plan #Date of BirthCertificate (ID) #2nd InsuranceInsurance ProviderPolicy HolderGroup/Plan #Date of BirthCertificate (ID) #Reason for Referral *Special ConsiderationsUpload Documents (X-Rays, Radiographs, etc.)Drag and Drop (or) Choose Files SubmitPlease do not fill in this field.