Only dental professionals should complete this form to refer patients for procedures.

The form is submitted securely and patient information is stored confidentially.

Referring practitioner

You will only need to complete this once per browser/device. It should be recalled subsequent occasions.

Patient Information

Contact details

Referral details

Tooth / Teeth

Palmer notation

Supporting attachments

Before starting

You will need this patient information to hand before completing the form:

  • their usual doctor's name and contact details
  • their relevant medical history
  • supporting digitised scans to upload as attachments.

If you prefer to print out a form, download the PDF in the panel below. Then you can post, email, fax it.

Form download

First page of Practitioner Referral for Procedure
Practitioner Referral for Procedure (PDF, 60.3KB)

Print this form out, fill it in, and bring it in for us if you prefer.