Dental Referral Form - Northwestern Health Unit

Referral type *

Self-referral (I and/or a family member needs dental care)
Agency referral (a service provider is referring the client for dental care)

Self-referral information

Date of self-referral

Community *

Client name

Client date of birth *

If the client is a child or is under the care of another decision-maker, please enter the appropriate contact information:

Contact name (if different than client named above)

Contact phone number

Contact email address

Email

Confirm Email

Explain the reason for referral (optional)

Please note:

NWHU dental services are provided for eligible residents of the Northwestern Health Unit catchment area. If you do not reside in this area, your information will be forwarded to the appropriate health unit.

Privacy Notice:

Personal information is collected under the authority of the Health Protection and Promotion Act and related legislation and in accordance with the Personal Health Information Protection Act and/or the (Municipal) Freedom of Information and Protection of Privacy Act. We collect only the personal information needed to provide public health programs and to plan and evaluate our services. Your information may be shared with others as required or permitted by law. For more information contact the health unit at 1-855-407-6453 or see the privacy statement on our website at www.nwhu.on.ca.

Agency referral information

Date of agency referral

Community *

Referring agency

Name of referring agent

Agency phone number

Referring agent email address

Email

Confirm Email

Is the client aware of this referral?

Yes
No

Client name

Client date of birth *

If the client is a child or is under the care of another decision-maker, please enter the appropriate contact information:

Contact name (if different than client named above)

Contact phone number

Contact email address

Email

Confirm Email

Explain the reason for referral (optional)

Please note:

NWHU dental services are provided for eligible residents of the Northwestern Health Unit catchment area. If you do not reside in this area, your information will be forwarded to the appropriate health unit.

Privacy Notice:

Personal information is collected under the authority of the Health Protection and Promotion Act and related legislation and in accordance with the Personal Health Information Protection Act and/or the (Municipal) Freedom of Information and Protection of Privacy Act. We collect only the personal information needed to provide public health programs and to plan and evaluate our services. Your information may be shared with others as required or permitted by law. For more information contact the health unit at 1-855-407-6453 or see the privacy statement on our website at www.nwhu.on.ca.