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(07) 3343 4880
Phone
Mon - Fri
9AM - 9PM
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Refer a Patient
For your convenience, you can refer patients electronically via our online form.
Download PDF format of Referral Form
Fields marked with an asterisk (
*
) are required.
Patient Details
Patient Name (Child's name)
*
Date of Birth
*
Address
Phone
Mobile
*
Email
*
Parent or Guardian
*
Reason for Referral
Urgent (appointment today)
Next available appointment
Clinical Details
*
Radiographs available?
Yes
No
Please specify
Medical History
Nil relevant
Please specify
Dental History
Referring Dentist
Name of Practice
*
Referring Dentist
*
Date of Referral
*
Telephone
*
Email
*
Objectives of Referral
Opinion, management of the above condition and provision of ongoing care
Opinion, management of the above condition with the patient returned to you for ongoing care
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*
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