Dentist Referral Date: (required) *TitleMr.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)Choose FileNo file chosenDelete uploaded fileChoose FileNo file chosenDelete uploaded fileChoose FileNo file chosenDelete uploaded fileChoose FileNo file chosenDelete uploaded fileChoose FileNo file chosenDelete uploaded fileAdditional comments: (required) *Dr. *Dr's Phone: (required) *Email Address: (required) * Submit 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: brandonperio@wcgwave.ca Office Hours Monday – 8:00am – 4:00pm ( *admin staff) Tuesday 8:00am – 5:00pm Wednesday 8:00am – 5:00pm Thursday 8:00am – 5:00pm Friday 8:00am – 5:00pm Saturday Closed Sunday Closed