Refer a patient — L'Empreinte Studio

Your details (referring colleague)

Practitioner's name *

Practice / organisation

Phone *

Email *

Patient information

Patient's first name *

Patient's last name *

Patient's phone

Patient's email

Patient's date of birth (optional)

Reason for referral

Preferred practitioner *

Reason *

Clinical details (optional)

Is this an emergency? *

Yes No

Additional message (optional)

Document (optional)

X-ray, letter or report

PDF or image, 5 MB maximum.

I agree that this information may be used by the L'Empreinte Studio practice to process this referral request, in accordance with the privacy policy. *

For a severe dental emergency (trauma, bleeding, significant swelling), please contact the practice directly by phone.

We do our best to get back to you as soon as possible.