Referrals

Brisbane Dental Implant Group invite you to use our online referral form below; alternatively, you can DOWNLOAD and fax/scan our referral form HERE

Please note, this form should be used by referring dentists or medical practitioners only

All fields marked * are required.

Patient details
Patient Name*
Email*
Phone (Home)
Phone (Work)
Mobile*
Date of Birth
DD slash MM slash YYYY
Doctor details
Referring Doctor*
Referrer Phone Number*
Provider Number
- Please phone me to discuss this case
Treatment Details
Referral Request
- Treatment plan
- Implant prosthetics
- Grafting
- Implant surgery
- Full case management
Additional Information
Attach your patient xrays, images, and reference material files here
File 1
Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 512 MB.
File 2
Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 512 MB.
File 3
Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 512 MB.
File 4
Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 512 MB.
File 5
Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 512 MB.
File 6
Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 512 MB.
Comments
This field is for validation purposes and should be left unchanged.

Monday to Thursday	8:30am – 4.30pm
Friday	8:30am – 3:30pm

Patient details