Referrals – Core Dental Specialty Group

REFERRALSCORE DENTAL GROUP

Contact Core Dental Group in Langley, and let a
friendly staff member answer your questions RMP, or
the services available within the practice.

Tel: 1.604.881.1381
Email: info@coredentalgroup.com

#105 – 8411 200th Street
Langley, British Columbia
Canada V2Y 0E7

We are a non-assignment office. All EDI claims will be submitted
on behalf of patients.

*Referring To (required):

*Referring Dentist (required):

*Dentist's Email (required):

*Dentist's Phone (required):

*Patient First Name, Last Name (required):

*Date of Birth (required):

*Patient Phone Number (required):

Patient's Email:

Reason For Referral:

Additional Details:

Treatment Area:
1817161514131211
2122232425262728
3132333435363738
4847464544434241

Attach Dental Imaging:

405 20020a 84th Avenue
Langley, British Columbia
Canada V2Y 5K9