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Secure Patient Referral Form

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  • Patient Details

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  • Referring Dentist's Details

  • Referral Details

  • To avoid micro-leakage following obturation, we will not be able to restore the access cavity with other restorative materials. If you require access for post, core or any other restorative procedure, kindly discuss this with us prior to referral.
  • X-Rays

    Please ensure that any existing X-rays are submitted / uploaded with all referrals
  • Please include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF
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    Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 64 MB.
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