REFER A PATIENT

Maxillo 3 Lacs Implantology and Maxillofacial Surgery Clinic

Get In Touch

Maxillo 3 Lacs
(514) 395-9896
[email protected]

65 Boulevard de la Cité-des-Jeunes
Suite 130, Vaudreuil-Dorion,
Quebec J7V 8C1

Monday 8:30 am – 4:00 pm
Tuesday 8:30 am – 4:00 pm
Wednesday 8:30 am – 4:00 pm
Thursday Closed
Friday 8:30 am – 4:00 pm
Saturday Closed
Sunday Closed

    PATIENT INFORMATION

    Patient First Name

    Patient Last Name

    Patient Phone

    Gender

    REFERRING DENTIST

    Referring Dentist First Name

    Referring Dentist Last Name

    Referring Dentist Phone Number

    Email

    Select a Surgeon

    Reason for Consultation

    Other

    Affected Teeth

    Kids Teeth
    Top Right






    Top Left






    Bottom Right






    Bottom Left






    Adult Teeth
    Top Right









    Top Left









    Bottom Right









    Bottom Left









    Radiograph

    Language

    Date

    Upload File: