Patient Referral Form

Please fill out this form to accurately capture what you would like us to attend to.

Referring Doctor Name (required) *

Referring Doctor Clinic (required)

Referring Doctor Contact Number (required)

Referring Doctor Email (required)

Patient Name (required)

Patient Contact Number (required)

Patient Email (required)

Relevant Medical History

Relevant Dental History

Any Previous X-rays (Y/N)

Yes No

Please attach any previous X-rays here (For CBCT Scans please send via WeTransfer or Google Drive to [email protected]) *

Referral Date

Reason for Referral / Message

IMPORTANT: Please note that if extractions are required, it is recommended to delay this until after our consultation appointment unless symptomatic.

Stay in the Loop with Summit Dental Care!