BCCH Dentistry Referral Form Instructions
This form contains 41 fields organized into 14 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Contact Phone Numbers | ||
| Day Phone | Text |
Please provide the primary daytime contact phone number.
|
| Cell Phone | Text |
Please provide the cell phone number for contact.
|
| Other Phone | Text |
Please provide any other additional contact phone number.
|
| Insurance Holder Information | ||
| Employer Name | Text |
Please provide the name of the employer for the insurance holder. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Insurance Holder Name | Text |
Please provide the full name of the insurance holder. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Employee Date of Birth | Date |
Please provide the date of birth of the employee. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Interpreter Information | ||
| Interpreter Required: Yes | Checkbox |
Check this box if an interpreter is required for the patient.
|
| Interpreter Language | Text |
Please provide the language required for interpretation services. Fill only if 'Interpreter Required: Yes' is 'Yes'.
Depends on:
Interpreter Required: Yes
|
| Mailing Address | ||
| Mailing Street Address | Text |
Enter the full mailing street address.
|
| City | Text |
Enter the city for the mailing address.
|
| Postal Code | Text |
Enter the postal code for the mailing address.
|
| MSP Number | ||
| MSP Number | Text |
Please provide the patient's Medical Services Plan (MSP) number.
|
| Parent's Name | ||
| Parent's Surname | Text |
Please enter the surname of the parent.
|
| Parent's First Name | Text |
Please enter the first name of the parent.
|
| PART III: Medical/dental information & reason for referral | ||
| Medical/Dental Information and Referral Reason | Text |
Provide all relevant medical and behavioral diagnoses, current medications, identified dental issues, and any relevant investigations for the referral.
|
| Patient Health and Gender Information | ||
| PHN (Care Card) | Text |
Enter the patient's Personal Health Number (PHN) as found on their Care Card.
|
| Female | Checkbox |
Check this box if the patient's gender is female.
|
| Male | Checkbox |
Check this box if the patient's gender is male.
|
| Other | Checkbox |
Check this box if the patient's gender is not female or male.
|
| Other Gender | Text |
Provide a specific gender identity if it is not Female or Male. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Patient Name and Date of Birth | ||
| Patient Surname | Text |
Enter the patient's last name.
|
| Patient First Name | Text |
Enter the patient's first name.
|
| Patient Date of Birth | Date |
Provide the patient's date of birth.
|
| Patient Age | Number |
Enter the patient's current age in years.
|
| Patient's Contact Address | ||
| Email Address | Text |
Please enter the patient's email address.
|
| Mailing Street Address | Text |
Please enter the patient's mailing street address.
|
| City | Text |
Please enter the city for the patient's mailing address.
|
| Postal Code | Text |
Please enter the postal code for the patient's mailing address.
|
| Primary Dental Insurance Details | ||
| Group Number | Text |
Please enter the group number of the dental insurance plan. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| ID Number | Text |
Please enter the identification number for the insured under this dental plan. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Insured Percentage Covered | Number |
Please enter the percentage of dental services covered by the insurance policy. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Yes | Checkbox |
Check this box if the patient has primary dental insurance.
|
| No | Checkbox |
Check this box if the patient does not have primary dental insurance.
|
| Insurance Company | Text |
Please enter the name of the primary dental insurance company. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Referring Professional's Contact Information | ||
| Referring Professional's Phone Number | Text |
Please provide the referring professional's primary phone number.
|
| Referring Professional's Fax Number | Text |
Please provide the referring professional's fax number.
|
| Referring Professional's Email Address | Text |
Please provide the referring professional's email address.
|
| Referring Professional's Name | ||
| Referring Professional's Surname | Text |
Please enter the referring professional's surname.
|
| Referring Professional's First Name | Text |
Please enter the referring professional's first name.
|
| Referring Professional's Designation | Text |
Please enter the referring professional's medical or dental designation (e.g., MD, DMD, DDS, or other).
|
| Signature | ||
| Referring Professional Signature | Text |
Please provide the referring professional's signature.
|