London Endodontics
Dr. Victor Wagner & Dr. Anu Bhalla
Dentist Information
Valid XHTML 1.0 Transitional


Patient Referral Form

If you wish to refer a case, we suggest using the form shown here to fax the pertinent information to us. It has been designed to be very efficient and to save you and your staff valuable time. It should also save your front desk a lot of phone time. The intent is for the administrative staff to fill in the contact information at the top, and for the clinical staff to complete the bottom part. Photocopies can easily be made as required. Please mail any films which you believe would be helpful, particularly if you are requesting a treatment appointment as opposed to a consultation only. Any requests for emergency treatment should be called in.

Please feel free to call if there are any questions.

Thank you.