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Dentist referral form
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YOUR FRIENDLY, LOCAL SMILE SPECIALISTS
03 962 0334
Thank you for your referral. Please include relevant information below.
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Your name
Your preferred contact details
eg phone and/or email address
Orthodontist (leave blank if no preference)
Dr Russell Lovatt
Dr Chrissy Bailey
Patient name
Name of parent/caregiver (if applicable)
Reason for referral
eg Class II, Class III, crossbite, crowding, deep bite, open bite, impacted teeth, spacing, missing/extra teeth, perio-ortho concerns, pre-restorative concerns, TMJ
Patient date of birth
School (if applicable)
Patient/caregiver contact details
*
eg address, phone number(s), email
Additional comments
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