Professional Referrals

At Northland Village Dental Centre, we are always accepting new patients, regardless of age. If you would like to refer a patient to our clinic, we welcome you to complete the form below. All information submitted will remain confidential.

Referring Doctor’s Information

Your Name:*

Your Office Name

Your Email Address*

Patient Information

Patient’s First Name:*

Patient's Phone Number:

Patient's Email Address:

Patient's Sex: *

Patient's Birthdate:

Patient’s Responsible Party (ex. parent or guardian)

Party's Name:

Party's Relationship to Patient:

Request an Appointment

Request an Appointment

Dental issues can get worse over time if neglected.

Contact Us

Contact Us

If you have any queries, please don’t hesitate to reach out to us.