Addressed to
Dr Adel Kauzman
Dr Benoît Lalonde
Dre Gisèle Mainville
Dre Nathalie Rel
Choice of the clinic
Montreal
Laval
Saint-Hubert
Date of request
Patient information
DOB
Clincian information
Do you prefer an email copy of the consultation letter ?
NO
YES
If yes, please provide your email address
REASON FOR CONSULTATION
Premalignant/malignant lesion
Soft tissue lesions(s)
Pain
NO
YES
Radiographic lesion(s)
Persistent oral burning sensation
Oral dryness
Trigeminal neuralgia
Persistent pain following endodontic or surgical treatment
Persistent headache
Muscular pain
TMJ dysfunction
Other reason
PHOTOS/RADIOGRAPHS
SUBMIT