Referral Form For Dentists


Please include relevant radiographs with your referral. If you wish for a post space to be created please make sure to note this in your referral.

If you wish to discuss a case with Dr Kim, please call on (03) 63347140
or directly on her mobile on 0405706508 or contact us through the Contact Form





Patient Info:

Name:
Address:
Phone:
Email:
D.O.B.




Practitioner Info:

Name:
Address:
Phone:
Email:
Tooth/Teeth Number(s):




Please tick the following required treatment(s):

Open Apex
Trauma
Resorption
Root Canal Treatment
Root Canal Re-Treatment
Separated Instrument Removal
Post/Silver Point Removal
Cracked Tooth
Diagnosis
Microsurgery (apical surgery, root resection, hemisection etc.)


 

Clinical Notes (please also include relevant medical history):
The patient's current pain level is:
Nil Mild Moderate Severe
Please indicate the restorative plan for any teeth to be
treated and if post space is required:
Regarding this patient, would you like to be contacted by:
Phone Letter Email

 

Attach a Radiograph/Scan:
Attach another Radiograph/Scan:
Note - depending on your connection speed and the file size of attached image(s), the process may take up to several minutes to complete.
Please keep your images under 3MB.


If you need to attach more than 2 Radiograph or Scan images, attach them in a single ZIP file. Zipping multiple image files will be processed and sent faster than processing them individually.

Note: Depending on the size of attachments it may take a few moments to process the submission. Please be patient and don't repeatedly click the submit button.