Referral Form

Firoozeh Samim D.D.S., M.Sc.,Dip.ABOMP, F.R.C.D.(C)

Specialist in Oral Medicine & Oral and Maxillofacial Pathology

firoozeh.samim [at]

McGill Faculty of Dentistry

Student/Staff Dental Clinic

Oral and Maxillofacial Pathology/ TMD and Orofacial Pain Clinic

752 Sherbrooke Ouest,

Montreal, Quebec H3A 1G1

T. 514-398-3155

E. clinic.dentistry [at]

(Send Referral Form by email)

Montreal General Hospital

Dept. of Oral and Maxillofacial Surgery

Mouth Diseases and TMD & Orofacial Pain Clinic

Room B3-131

1650 Cedar Ave, Montreal, Quebec H3G 1A4

Phone: 514-934-8063

Fax: 514-934-8340

(Send Referral Form by FAX)

RAMQ covers only 1 hospital visit

Patient Information

Reason for Referral

Indicate any special factors, either dental or medical, such as known allergies, specific medical problems relevant to diagnosis and treatment.