• Saskatoon Office
150-1820 McOrmond Drive
PHONE 306-249-5300
FAX 306-249-5305
receptionSK@imageorthodontics.ca
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A GREAT SMILE
CAN CHANGE A LIFE

Dr. Ryan Lacoursière

CERTIFIED SPECIALIST
IN ORTHODONTICS

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DENTIST REFERRAL

Office Location Saskatoon Office
Lloydminster Office
Date  
Referring Doctor  
Staff Contact Name  
Office Phone  
Patient Name  
Patient DOB  
Home Phone  
Parent/Guardian  
Alternative Phone  
Preferred Orthodontist No Preference
Dr. Ryan Lacoursière
Specific Concerns

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If patient has panorex or x-rays, please email to:
Saskatoon office - receptionSK@imageorthodontics.ca
Lloydminster office - receptionAB@imageorthodontics.ca