Tooth Town Referral Form
Patient Details
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Email Address
example@example.com
Parent Mobile
*
0412 345 678
Referral Details
Appointment Preference
*
First Specialist Appointment Available
Dr Jacqui Fechney
Dr Steve Kazoullis
Dr Helen Fung
Early interceptive orthodontics
Myofunctional therapy (Michelle Sankey)
Special Needs Dentistry (Dr Candy Fung)
Other
Reason for Referral
*
GA / Behaviour Management
Caries
Abscess
Trauma
Tongue Tie
Early Interceptive Orthodontics
Airway Management
Special Needs
Other
Medical History, any additional information
Objectives of Referral
*
Opinion, management of the above condition and provision of ongoing care
Opinion, management of the above condition with the patient returned to you for ongoing care
Radiographs Enclosed
*
Yes, please see attached files
No, none available
No, radiographs/photos emailed to info@toothtown.com.au
No, please email signed Release of Records form
Please access OPG via Dental Diagnostics portal
Please access OPG via QXR portal
Please access OPG via QScan portal
Please access OPG via i-Med portal
Please access OPG via Exact portal
Please access OPG via Citiscan portal
Other
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Do you require a record of release form completed to transfer any records not already provided?
*
Yes
No
Referrer's Details
Referring Clinician
*
Dr.
Mr
Mrs
Ms
Miss
Prefix
First Name
Last Name
Provider Number
Contact Number
*
0412 345 678
Practice Name
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email address (a copy will be emailed to this address for your records)
*
example@example.com
Would you like a copy of this referral emailed to the parents?
*
Yes
No
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