Referral form

You do not need a referral to attend an orthodontist.
This form is to help us work with our referring dentists.

Patient information:

First Name

Surname

Date of Birth

Sex

Male Female

Address

Suburb

Postcode

Phone

Referred By

Dentists address

Conservative treatment completed

I await your report before treatment

I will send relevant radiographs

OPG

Lateral Ceph

Periapicals

Reason for Referral

Crowding

Cross Bite

Perio-ortho concerns

Spacing

Excessive overjet

Open bite

Deep bite

Reverse overjet

Missing/Extra teeth

Second Opinion

Please let me know

Advice and necessary treatment

Suggest treatment that could be carried out by me

Please discuss with patient alternative treatments

Other (please specify)

Comment