Online Referral Form

Will the dental treatment be performed under Sedation? *

YesNoPatient undecided and would like to discuss options

Who will be performing the dental treatment in our clinic? *

Our On-site DentistThe Referring DentistBoth (General dentistry will be provided by the Referring Dentist and surgical procedures will be provided by Our On-site Dentist)

How long will the dental procedure take? *

Up to 1 hourUp to 1.5 hoursUp to 2 hoursMore than 2 hours

How long will the dental procedure performed by the Referring Dentist take? *

Up to 1 hourUp to 1.5 hoursUp to 2 hoursMore than 2 hours

Patient Information

Patient's Name *

Patient's Date of Birth *

Patient's Contact Number *

The reason for the referral. (Please provide as much information as possible) *

Supporting X-rays and documents *

Radiology practice where the X-ray was taken *

Please upload patient X-rays and documents *

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Max. file size: 30 MB

Please upload other X-rays and documents if available

Browse

Max. file size: 30 MB

Referring Practitioner

Practitioner's Name *

Practice Name *

Practitioner's Contact Number *

Practice Address *

Street address

City *

State *

Postcode *