Refer A Patient to Dr. Grabrowski

Dr. Graham Grabowski Referral Form

Practices referring patients to Dr. Graham Grabowski, please use this form to send us your patient’s information. Alternatively, if you do not wish to use the online form submission please download the PDF form from the link to the right. If you have any questions about this form, do not hesitate to contact us directly at (604) 736-0440 or email us at prior to submitting the form.

Please fill out the information below as completely as possible.

IMPORTANT: When you click submit, you will receive a successful confirmation message. If you do not see the confirmation message, you will need to check through the form and complete any missing information. A confirmation e-mail will be sent to you confirming the successful submission to Dr. Graham Grabowski.

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    Please Select:

    Patient Information
    Referral Information
    Reason for Referral
    Third MolarsDental ExtractionBone AugmentationImplantsTooth ExposurePathology/BiopsyOrthodontic ImplantAlveolar CleftFacial TraumaSedationOther
    Teeth To Be Extracted
    55 54 53 52 51 61 62 63 64 65
    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    85 84 83 82 81 71 72 73 74 75
    MailedE-MailedAttachedWith PatientPlease Obtain
    Files & Images

    Acceptable File Types: JPG. JPEG, PNG, GIF or PDF - Max Per Image Size (10 Mb)

    *NOTE* If uploading numerous files, this form may take a few minutes to submit. Please wait till you have the success confirmation message.

    Form Submissions sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

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