Name of Parent/Guardian if the patient is of minor age:
Panorex
 
 
Radiograph
 

REASON FOR REFERRAL

DENTAL INSURANCE INFORMATION (Please complete in full)

 
Primary
Secondary

Lakewood Dental
4122 - 15th Avenue
Prince George, BC
Canada
V2M 1V9

Telephone
(250) 614-1828

Toll Free
1-866-614-1828

Facsimile
(250) 614-1898

9629 100th Avenue
Fort St John, BC
V1J 1Y2

Telephone
(250) 787-1848

Horizon Dental
4663 Park Avenue
Terrace, BC
V8G 1V9

Telephone
(250) 635-1213

Toll Free
1-800-549-5594