Toowoomba

07 4639 1798

Online Patient Referral

This form is for professionals only. If you are a patient, please use the appointment request form.

Practitioner Details

Title

Name

Practice

Provider Number

Contact Email

Contact Phone

Patient Details

Full Name

DOB

Patient Phone

Location

Toowoomba (Wednesdays, Thursdays)

Issue/s

Expose & ligate impacted tooth
Removal of teeth
Dental implants
Corrective jaw surgery

Preprosthetic surgery
Oral pathology
Maxillofacial trauma
Other (Please detail below)

Tooth Number/s

Clinical Notes

Max 1000 characters

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Please attach any reports related to the patient e.g. OPG / X-RAY / PA (Max file size 1024 KB) CLICK TO CHOOSE FILE >