Dentist Referral Date: (required) Title Mr.Mrs.Ms. 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 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