Patient Referral form - Pristine Dental Group

Refer your Patient To PRISTINE Hands

Fill in the secure PATIENT REFERRAL FORM below with as much detail as possible.
Our team will get in touch with your patient promptly and keep you informed throughout their treatment journey.

Referring Dentist Details

Please provide details of the referring dentist below.

Dentist First Name *

Dentist Surname *

Contact Number *

Email Address *

Street Address *

Address Line 2

City

State/Province

Country

Postal Code

Patient Details

Please provide as much detail about the patient below.

Preferred Title *

Date of Birth *

First Name *

Surname *

Contact Number *

Email Address *

Street Address *

Address Line 2

City

State/Province

Country

Postal Code

Referral Details

Please indicate if the patient experiences any of the following:

Heart conditionsHigh blood pressureDiabetesKidney diseaseBleeding tendenciesBlood borne virusSmokerExcessive alcohol consumptionAsthmaChest conditionsEpilepsy/fits/convulsionsLiver diseaseSleep apnoeaPregnant or breast feedingNeurological disordersRecreational drug use

Other significant medical condition:

If chose any of the above, please provide more details:

Does the patient have any allergies? *

YesNo

If yes, what is it?

Treatment Details

Please indicate referral treatment needs:

Conservation

Extractions

Implants

Other Treatments Required

Upload Radiographs (ZIP/PDF/JPG only):

If no radiographs, specify the reason:

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