Community Dental Services: Dentist Referral

We promise to work ethically with you and return your patient back to you. We will involve and inform you of your patient’s treatment every step of the way.

We will support you and your dental clinic, mentor and help you develop your skills & CDP.

We will endeavour to treat your patients with the utmost care and diligence.

Simply fill in the below form to refer a patient and one of our dentists will contact you to arrange further details.

Referring Practitioner





Patient Details







Private Health Insurance
YesNo


History

Oral Condition
ExcellentAbove AverageAverageBelow AveragePoor

Muscosa
NormalAbnormal

Muscosa Details

Teeth Missing

Upper Left
87654321

Upper Right
12345678

Lower Left
87654321

Lower Right
12345678

Pain
0++++++

Swelling
0++++++

Vital
YesNo

PA Lesion
YesNo

Referral Details

Referring
ImplantologyOrthodonticsEndodonticsCosmetic DentistryProsthodonticsHygienePeriodonticsPaediatric DentistryOral SurgeryIV SedationFacial TreatmentsInvisalignOther


I would like to be present during the consultation/treatment
YesNo

I would like the dentist to contact me to discuss the case
YesNo


Has the patient been given an estimate of our fees?
YesNo