Dentist Referral

    Date: (required)

    Title

    Patient Name: (required)

    Address: (required)

    Postal Code: (required)

    Name of Parent/Guardian: (required)

    Telephone: residence (required)

    Telephone: work (required)

    Patient’s Date of Birth (day/month/year): (required)

    Specific Concerns (if any) (required)

    Relevant history (required)

    Attach files (required)




    Panorex must go via email to info@brandonperio.com

    Please call patient to schedule an appointment (required)

    Additional comments: (required)

    Referred by: (required)
    Dr.

    Dr's Phone: (required)

    Email Address: (required)

    Verify Your not a robot

    For a Consultation

    Call: 204-726-1211

    No Referral Necessary

    Our Location

    1100 Richmond Avenue, Unit B
    Brandon, MB
    R7A 1M6

    Map

    View Larger Map

    Phone: (204) 726-1211
    Fax: (204) 571-1560
    Email: info@brandonperio.com

    Office Hours

    *Monday 8:00am – 4:00pm
    Tuesday 8:30am – 4:30pm
    Wednesday 8:30am – 4:30pm
    Thursday 8:30am – 4:30pm
    Friday 8:30am – 4:30pm
    Saturday Closed
    Sunday Closed

    * Administration staff only