Only dental professionals should complete this form to refer patients for procedures.
The form is submitted securely and patient information is stored confidentially.
You will need this patient information to hand before completing the form:
- patient's name, date of birth, and contact details
- patient's 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.