Book Now

Home
Treatment
Referrals
About Us
- Price Guide
Contact
Book Now

For Referrers

Home
Online Referrals

Online Referrals

Assisting General Dental Providers

Specialist Dentistry is here to assist you and your patients in achieving the best and healthiest smile.

Complete the form below to refer your patient to Specialist Dentistry. Once received, our team will review the information and contact you on next steps and supply of relevant documentation.

If you would like a referral pack or to discuss a patient case, please contact our friendly reception team today.

Online Referral

Referral Treatment Type(Required)

Please select one of the following:

Patient Details

Patient First Name(Required)

Patient Last Name(Required)

Patient DOB(Required)

Patient Phone(Required)

Provider(Required)

Patient Email(Required)

Reason for Referral(Required)

Please include any relevant medical history

Referral Details

Referring Practice(Required)

Referring Provider First Name(Required)

Referring Provider Last Name(Required)

Practice Email(Required)

Practice Phone(Required)

Is a post space required?

Yes

At Endodontist discretion

Not applicable

Restoration Preference

We will endeavour to place a permanent core restoration at the completion of treatment for your convenience.

Place Permanent Core

Place Temporary Restoration

Place Post (if required)

Not applicable

Have you done a previous sleep study?

Yes

Unsure

Are radiographs enclosed (attached below)?

Yes

Can not upload

Additional Notes?

Blood Thinners

Bisphosphonates/Prolia

Methotrexate

Immune Suppressants

Limited Access

Anxiety/Phobia

Are radiographs enclosed (attached below)?

Yes

Can not upload

Additional Notes?

Blood Thinners

Bisphosphonates/Prolia

Methotrexate

Immune Suppressants

Limited Access

Anxiety/Phobia

Are radiographs enclosed (attached below)?

Yes

Can not upload

Attachment Uploads

Drop files here or

Max. file size: 1 GB.

Medical History, etc.

Additional Comments

Any additional information, please provide below.

Resource Centre

How Can We Help?

Taking the first step on your treatment journey has never been easier. Simply fill out the form below and one of our friendly reception team will get back to you.

URL

This field is for validation purposes and should be left unchanged.

Name(Required)

Contact Number(Required)

Email(Required)

Contact Method(Required)

Location(Required)

Please tell us about your oral health concerns