Patient Referral Form to Dr Sing Ying (Paediatric Dental Specialist)

Patient Referral Form to Dr Sing Ying (Paediatric Dental Specialist)

*FOR MEDICAL PROFESSIONALS ONLY* Please provide patient details and reason for referral to ensure proper care.
Referring Doctor's Name*

Given NameSurname
Medical/Dental Clinic Name*
Doctor's Email Address*
example@example.com
Doctor/Clinic Phone Number*

Area CodePhone Number
Patient's Full Name*

Given NameSurname
Patient's Date of Birth*

DayMonthYear
Date
Parent/Guardian Contact Number*

Area CodePhone Number
Reason(s) for Referral (can choose multiple)*

Treatment under General anaesthesia (GA)Treatment under Nitrous oxide sedationSpecial needsComprehensive dental treatment / dental clearanceDental traumaDental caries (SSC / pulpotomy / pulpectomy)Dental anomalies (MIH, Dental Fluorosis, Amelogenesis Imperfecta, dentinogenesis imperfecta)Surgical (impacted tooth / supernumerary / odontomes / autotransplant)Other
Others
Urgency of Referral*

RoutineSoonUrgentEmergency
Relevant Medical/Dental History*
Patient preferred clinic location (can choose multiple)*

KDSC, KLArteestic Dental Bangsar South, KLAugust Dental Surgery SerembanGrace Chieng Dental, KuchingOnline consultation
Attach Relevant Documents (e.g., IOPA / OPG / L.Ceph / photos / reports)

Cancelof
Would you like the patient to return to your care once Dr. Singying has completed the treatment?

YesNo, the patient can continue their care under Dr Sing YingOther
I hereby declare that all information provided in this referral form is true and accurate to the best of my knowledge. I consent to the collection, use, and processing of this personal data by the clinic in accordance with the Personal Data Protection Act 2010 (PDPA) for the purposes of patient assessment, treatment planning, and communication with the patient’s parent or legal guardian regarding this referral.

I understand that the information provided may be shared with relevant healthcare professionals involved in the patient’s care where necessary.

*Our team will contact the parent directly to arrange the appointment*
Should be Empty: