Referral form

Thank you for referring your patient to the Dr. Gerald Niznick College of Dentistry. We are currently accepting referrals for Radiology, Graduate Orthodontics, Graduate Periodontics, Graduate Prosthodontics, Graduate Oral Surgery, TMD, DSM and Oral Pathology. When referring a patient, it is the provider’s responsibility to inform the patient of the exact purpose of the referral. The patient should understand that they may not necessarily be accepted for treatment at our clinics. To avoid delay in the diagnosis and treatment of your patient, please complete this form in full.

Please note this referral is for limited treatment only, comprehensive care would continue at your private practice clinic.

Dentist's information

Please format as 204-123-4567.
Please format as 204-123-4567.

 

 

Patient's information

Please format as 204-123-4567.
Please format as 204-123-4567.

Patient coverage

Does the patient have insurance coverage (e.g., insurance, social assistance, NIHB)?
Please be advised we do not accept assignment of benefits.
PRIVATE INSURANCE
Who is the policy holder
GOVERNMENT INSURANCE
Type of government insurance

 

 

Reason for referral


Oral Pathology is only accepting referrals from UM Affiliates (Mount Carmel and Access Downtown).

Is an implant required?
Are radiographs available?

Please email radiographs to oral_radiology@umanitoba.ca.

Will the patient undergo implant prosthetics in your private practice?
Will a radiographic/surgical guide be provided?
Will a surgical guide be printed after digital implant planning in collaboration with the lab of your choice?

For CBCT referrals
Referral reason
Toothing image area
Numbered teeth divided into left, right, upper and lower quadrants

Please indicate requested location based on the areas listed below.

Quad 1
Quad 2
Quad 3
Quad 4

 

 


Notice Regarding Collection, Use, and Disclosure of Personal Health Information by the University

Your personal health information is being collected under the authority of The University of Manitoba Act. The information you provide will be used by the University for the purpose of setting up your patient record with the Dr. Gerald Niznick College of Dentistry and booking your initial screening. Your personal health information may be disclosed to insurance companies for billing purposes. Your personal health information will not be used or disclosed for other purposes, unless permitted by The Personal Health Information Act (PHIA). If you have any questions about the collection of your personal health information, contact the Access & Privacy Office (tel. 204-474-9462), 233 Elizabeth Dafoe Library, University of Manitoba, Winnipeg, MB, R3T 2N2.


Contact us

Dr. Gerald Niznick College of Dentistry
Room D113, 780 Bannatyne Avenue
University of Manitoba – Bannatyne Campus
Winnipeg, MB R3E 0W2, Canada

info_dent@umanitoba.ca
204-789-3497
204-789-3950