Please use this portal to refer your patients to us. Note, this system is fully encrypted using 256 bit SSL. Referring Dentist Details Referring Dentist Details Practice Name * Dentist name * Your contact number * If you recieve an email from us please ensure you check your Spam box! Email * Email confirmation * Patient Details Patient Details To avoid any delay with your referral, please check that all details are correctly filled in before sending us the form. Title * Mrs.Ms.MissMr.Master Name * Date of birth * Telephone number * Email * Email Confirmation * Address * Postal code * SECTION 1: Previous treatments Has the patient had any treatment with us before? * NoYes SECTION 2: What referral treatment are you referring the patient for? Treatment Requested * Periodontics Prosthodontics Endodontics Implants OPG Oral Medicine Facial Rejuvenation Orthodontics Oral Surgery CBCT Sedation Other Other - Treatment Requested 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. Add your comments here: 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 File name: File size: Additional X-rays or relevant attachments File name: File size: Additional X-rays or relevant attachments File name: File size: Additional X-rays or relevant attachments File name: File size: Validate Email
