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
Date Format: 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.
File 2
Accepted file types: jpg, gif, png, pdf, doc, docx.
File 3
Accepted file types: jpg, gif, png, pdf, doc, docx.
File 4
Accepted file types: jpg, gif, png, pdf, doc, docx.
File 5
Accepted file types: jpg, gif, png, pdf, doc, docx.
File 6
Accepted file types: jpg, gif, png, pdf, doc, docx.
Email
This field is for validation purposes and should be left unchanged.

Want more information on how we can replace your missing teeth or dentures?

Contact Details

Phone (07) 3244 2400
Address 19 Emlyn Street
Coorparoo QLD 4151
Hours
Monday to Thursday 8:30am – 4.30pm
Friday 8:30am – 3:30pm

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Expressions of Interest

Dr Michael Howard invites like-minded medical professionals to join him in an implant study group