Information for Referrers

Patient Details

Name

DOB (DD/MM/YY)

Address

Postcode

Parent/ Guardian Name

Contact number

Referral for:

Consultation and treatmentConsultation and adviceDental cariesHypomineralised teethTraumaExtractionSpace maintenanceNitrous oxide sedationGeneral anaesthesia

Please confirm teeth requiring treatment and any comments as needed

Behaviour:

CalmUncooperativeAnxious

Comments:

Radiographs:

BitewingsPAOPG

Upload Radiographs/Images:

Accepted file formats gif, png, jpg, jpeg, pdf
Please email any additional radiographs/images to reception@kewpaediatricgroup.com.au please include your name in the email.

Referring Practitioner

Name

Practice Name

Address

Postcode

Phone Number

Email Address