Patient Referral Form

This form is intended for GDC registered dentists to refer patients to us only. If you are a patient please go to our Contact Us page to get in touch.

Referral Details

Please enter a valid name
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Please enter a valid address
Please enter a valid email address
Please enter a valid contact number

PATIENT DETAILS

Please enter a valid name
Please enter a valid email address
Please enter a valid address
Please Fill any of Two Mobile Number Or Home Phone Number

Please indicate referral treatment needs in the relevant sections below.

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Note: IRMER regulations require all radiographs and scans to be reviewed and reported by the referring practitioner or a radiologist. We do not report on CT scans or OPGs but can arrange for it to be reported by a radiologist at an additional cost, or you can send the scan/x-ray to the radiologist yourself.
Please confirm your preference below:

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(Optional) Radiographs & Clinical Photographs

If you would like to attach any radiographs, clinical photographs or any documents that you feel would be of use, please use the upload facility below.

(If you are attaching files it will take upto a minute to submit, once you have clicked submit please wait for the page to refresh).

Select Files (Maximum of 2 files)

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