Dr. Elliott A. Schwartz & Associates
Certified Specialist in Children's Dentistry
106 Sheppard Ave West, Toronto

Call us at (416) 224-2300

Professional Referral Form

We appreciate the confidence you show in us by referring your patient to our practice for paediatric dental care. Please use the form below to provide us with the patient and parent information of whom you are referring.

Referring Doctor:

Doctor First Name:
Doctor Last Name:
Doctor Email Address:
Doctor Phone Number:
*required field

Radiographs to follow:

Submitted by:


If you need an immediate appointment please call our office at (416) 224-2300 and talk to our staff, and we will try to accommodate your patient. Please make your patient's parent or guardian is aware of our Financial Policy and if they have the time, they can fill out the child's Health and Dental History form online.

Patient Information:

Patient First Name:
Patient Last Name:
Patient Email Address:
Patient Phone Number:
*required field

Reason for Referral:

Removable Prosthodontics
Fixed Prosthodontics

Additional Information:

We thank you for your referral and will contact your office to confirm intake. If there is anything we can do to serve you better, please let us know.

Contact Our Office

Our office accepts Emergency Appointments. Contact Us for more information.

Call us at (416) 224-2300
106 Sheppard Ave West,
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Copyright 2017. Dr. Elliott A. Schwartz