Specialist and General Referrals

To refer your patient to see one of our clinicians please complete and submit the online form below.

If you are referring your patient for an OPG or CBCT scan, please click here.

Please supply as much information as possible. If you have any questions or difficulty using this form, please call or email us.

Patient details:

* required fields

Patient title*
Full name of patient*
Date of birth*
Telephone* (landline and/or mobile)
Email address*
Address

Referring dentist details:

Full name of referring dentist*
Practice*
Position
Email Address*
Telephone*
Practice Address

Reasons for referral:

Periodontics

Generalised Disease
Localised Disease
Gingival Recession

Endodontics

Opinion/Assessment
Primary Treatment
Retreatment

Implants / Prosthodontics

Implant assessment / planning
Bone volume assessment
Sinus assessment / graft planning
Complex restorative assessment
Full mouth rehabilitation

Clinical details / additional information

Radiographs

Please provide relevant radiographs for all referrals and ensure the exposure date/s are stated. If radiographs are not available, please indicate below:

No relevant imaging available
Unable to attach (due to file size or technical issue)

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Send form

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