To avoid any delay with your referral, please check that all details are correctly filled in before sending us the form!

SECTION 1: Previous treatments

SECTION 2: What referral treatment are you referring the patient for?

SECTION 3: If you are referring your patient for OPG or CBCT, please note that we require a justification for exposure. Please note that we are unable to report of the Xrays and it remains your responsibility to do so.

SECTION 4: If you are referring your patient for treatment with our Endodontist or Oral Surgeon, please note that you must provide xrays (either as apical xrays or OPG)

Any X-rays or relevant attachments