BCCH Dentistry Referral Form Completed Form Examples and Samples

Explore practical examples of the BCCH Dentistry Referral Form. See how to accurately fill out patient demographics, insurance details, and clinical referral information for BC Children's Hospital.
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Completed BCCH Dentistry Referral Form for pediatric patient

Automated BCCH Dentistry Referral Form Processing

How this form was filled:

This example demonstrates how an AI model can parse a physician's informal referral note to extract clinical, demographic, and insurance information, then populate the BCCH Dentistry Referral Form. The AI accurately mapped scattered details such as the patient's PHN, the referring professional's MSP number, and complex insurance coverage details into the standardized form fields.

Source document used: Physician Referral Correspondence

Subject: Dental Referral for Liam Miller (DOB: 05/12/2018) 

Dear BCCH Dental Clinic, 

I am writing to refer my patient, Liam Miller, age 7, for specialized evaluation and potential treatment. Liam has been diagnosed with moderate Autism Spectrum Disorder and presents with significant early childhood caries that are difficult to manage in a standard office environment. He is currently taking 5mg of Melatonin nightly for sleep support. 

His PHN is 9876543210. His mother, Sarah Miller, is his primary contact and can be reached via her cell at 604-555-0198 or at her work line, 604-555-9999, during the day. They reside at 1234 Maple Leaf Drive, Vancouver, V6B 1A1. Sarah can be reached by email at [email protected] for booking coordination. They do have primary dental insurance through Pacific Blue Cross (Group: 888777, ID: PBC123456789). The plan is held by Sarah Miller (DOB: 02/20/1985), who is employed at Tech Solutions Inc. The policy covers 80% of major restorative procedures. 

Regarding my office details: I am Dr. Marcus Thorne (DMD). My office is located at 456 Broadway St, Vancouver, V5T 1W4, and my MSP practitioner number is G998877. You can reach my team at 604-555-7777 or fax us at 604-555-7778 for any additional records. I have attached the recent bitewing radiographs and clinical photos to this email. Please let me know if you need any further information to facilitate this referral. 

Sincerely, Dr. Marcus Thorne, DMD.

Information used to fill out the document:

  • Patient Details: Liam Miller, DOB 05/12/2018, PHN 9876543210
  • Parent/Guardian: Sarah Miller, Cell 604-555-0198
  • Insurance Information: Pacific Blue Cross, Group 888777, 80% coverage
  • Referring Provider: Dr. Marcus Thorne, DMD, MSP G998877
  • Reason for Referral: Autism Spectrum Disorder, early childhood caries
  • Office Location: 456 Broadway St, Vancouver, V5T 1W4

What this filled form sample shows:

  • Contextual Extraction: AI identified the parent's contact info vs the patient's demographics.
  • Insurance Mapping: Automatically categorized Group numbers and coverage percentages from prose.
  • Credential Handling: Parsed professional titles and MSP numbers from signature blocks.
  • Medical Logic: Identified specific clinical diagnosis codes and medications from the narrative.

Form specifications and details:

Form Name: BCCH Dentistry Referral Form
Organization: BC Children’s Hospital
Department: Department of Dentistry
Use Case: Pediatric dental specialist referral
Target Audience: Dental professionals and office administrators
Categories: referral forms
Created: May 19, 2026 05:43 PM
Completed BCCH Dentistry Referral Form for pediatric patient