Refer a patient

This page is for use by health professionals only.
Parents/guardians should use the “register to be a patient” page.

Referring Practitioner Name *

Referring Practitioner Occupation *

Referring Practitioner Practice Name *

Referring Practitioner Email *

Patient Name *

First

Last

Patient DOB *//

Best Contact Person Name & Email / Phone *

Brief details or referral *

Urgent Referral

File Upload

Click or drag a file to this area to upload.

81 Reservoir Rd,
Strathdale VIC 3550

Mon-Fri: 9am-5pm
Sat: 9am-1pm
Sun: Closed

Where little teeth matter most