Dentist referral form

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

YOUR FRIENDLY, LOCAL SMILE SPECIALISTS

Thank you