ONLINE FORM - FOR DENTAL PROFESSIONALS ONLY *

*for patients wanting to book an appointment, please have your dental office send us a referral.

Online Form

To

Dr. Andrew Han

Dr. Michelle Lee

Referring Dentist:

Dentist Email:

Address

Phone Number

Examination requested for:

Complete Periodontal Evaluation

Specific Exam (Localized Area)

Implant Consult & Treatment

Radiographs

Not provided - please take

Given to Patient

Being Mailed

Upload Files

Indicate area(s) of concern:

Patient Name:

Telephone Number:

Date of Birth:

Date:

File Upload

Maximum file size: 67.11MB

If you are human, leave this field blank.

Feel free to use our downloadable referral form for Vancouver or for Dr. Han’s satellite office in Abbotsford.