Huronia Maxillofacial Radiology Accessibility Statement

Huronia Maxillofacial Radiology is committed to facilitating the accessibility and usability of its website, hmfr.ca, for everyone. Huronia Maxillofacial Radiology aims to comply with all applicable standards, including the World Wide Web Consortium's Web Content Accessibility Guidelines 2.0 up to Level AA (WCAG 2.0 AA). Huronia Maxillofacial Radiology is proud of the efforts that we have completed and that are in-progress to ensure that our website is accessible to everyone.

If you experience any difficulty in accessing any part of this website, please feel free to call us at 416-440-3892 or email us at info@hmfr.ca and we will work with you to provide the information or service you seek through an alternate communication method that is accessible for you consistent with applicable law (for example, through telephone support).

Home › Doctor Resources › Referral Form

Download our PDF form here.

Referral Form

    Patient Information

    Patient Name (required)

    Appointment date & time

    Referring Doctor's Email (required)

    D.O.B. (required)

    Telephone (required)

    Approx. fee

    Please specify which office to send this form:

    Toronto OfficeBarrie Office

    Cone Beam Computer Tomography

    TMJ (please check all that apply):closeopenbite registration

    Airway Analysis

    3D images

    Implants

    (please check areas of interest):
    87654321 1: | 2:12345678
    87654321 4: | 3: 12345678

    patient will bring stent

    Image output

    Measurements:
    Vertical measurements made from a minimum of crestal width.

    Hard copy printsDICOM filesViewing softwareSimplant file

    Email images to

    Conventional Imaging

    PanoramicLateral cephalometricCephalometric analysisPosterior-anterior cephalometriclateral cervical spinewith bite

    Digital Photography

    extraoralintraoral3D facial photographic scan

    Instructions and patient history

    Referred by Doctor (required)

    Date

    For your records, a copy of this form will also be sent to the email provided above.