Call us at 416-224-2300

Dr. Elliott A. Schwartz
& Associates

Certified Specialist in Children's Dentistry

106 Sheppard Ave West,

Free Parking
  TTC Access

Professional Patient Referral

We appreciate the confidence you show in us by referring your patient to our practice for Paediatric Dental Care. Please use the below form to provide us with the Patient and Parent Information of whom you are referring.

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 sure your Patient's Parent is aware of our Financial Policy and if they have the time to download and fill out the child's Patient Information : Health and Dental History, form.

Referring Doctor/Dentist

Doctor's Name*

Doctor's Telephone Number*

Doctor's Email Address*

Patient Information

Patient's Name*


Contact Parent's Name*

Parent's Address*

Email Address*

Cell Phone*

Home Phone*

Insurance Coverage:*

Yes   |   No

Are there X-Rays Available?

Yes   |   No

Please email any X-Rays to

Radiographs to follow:

By Email   |   Via Post Mail

Reason for Referral

Do you feel that this Child will need a General Anaesthetic at North York General Hospital to treat their Dental Condition.

Yes   |   No

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.

Patient Information:
Health & Dental History

We encourage you to download this comprehensive PDF Packet, fill it out and bring it with you on your first visit to our office.