Once you submit the form below, we will contact your patient within 2 business days. We look forward to working with you.

Patient Name

First Name

Last Name

Parent/Caregiver Name

First Name

Last Name

Phone

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Referring Office

Referring Doctor

First Name

Last Name

Office Phone/Email

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Any Radiographs?

Treatment and Comment

After Treatment

(236) 453-1777
hello@toothstory.ca

Hours
Mon 8am–4pm
Tue 8am–4pm
Wed 8am–4pm
Thur 9am–5pm
Fri 8am–4pm