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Specialist referrers

Referring your patients is simple! Just fill out the form below, and our friendly team will be in touch as soon as possible.

Specialist Referral

Patient Name(Required)

Date of Birth(Required)

Gender

Parent Name

Address

Street Address Address Line 2 City Postcode

Phone Number

Mobile Phone(Required)

Appointment with:

Dr. Prashanth Kumar Dhanpal

Dr. Andrea Fenwicke

No Preference

Reasons for referral :

Caries/Cavities

Enamel Hypoplasia/Hypomineralisation

Abscess

Over-Retained Teeth

Trauma/Fracture

Supernumerary

Orthodontic

Other

Details

Treatment to Date

Treatment required:

Restoration

Pulpotomy

Stainless Steel Crown

Extraction/Surgical Removal

Fissure Sealant

Minor Oral Surgery

Medical History:

Objectives of Referral:(Required)

General Care

Opinion Only

Opinion & Management of Specific Condition

Radiographs Attached:

Bitewing

Cephalogram

Periapical

Occlusal

OPG

Tomogram/CT

Upload Radiographs

Drop files here or

Max. file size: 128 MB.

Referrer’s Name:(Required)

Referrer’s Email:(Required)

Referrer’s Phone Number:(Required)

Address

CAPTCHA

1300 466 773
02 67020224
Info@tamworthpd.net.au
www.tamworthpd.net.au
Shop 1 62/78 Bridge St, West Tamworth NSW 2340

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1300 466 773
info@nspd.net.au
www.nspd.net.au
Unit 1, 19-23 Bridge Street, Pymble NSW 2073

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02 8413 8576
info@nspd.net.au
www.nbpd.net.au
Unit 11 22-26 Fisher Road, Dee Why NSW 2099

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Specialist Referral