Refer a patientConsultationAsterisks (*) indicate mandatory fields.Referred to*Dr Éric MorinDr Donald GarfieldDr Joël AbikhzerNo preferenceDate* Patient name*Date of birth* Phone*Cell phoneReferred by*Reason for consultation*ExtractionSurgical exposurePathologyTMJApicoectomyImplantBone graftOrthognathic surgeryTraumaTooth (teeth) numberRemarksX-Ray*NoGiven to patientAttached to present formSent separatelyJoin an X-Ray Drop files here or Accepted file types: jpg, jpeg, png, pdf, zip.jpeg, png, pdf, zip - 5Mb max.Appointment*Please contact the patient to book an appointmentThe patient will call to book an appointmentThe patient already has an appointment onDate* Time* This iframe contains the logic required to handle Ajax powered Gravity Forms.