Prosthodontics referral form Please fill out all fields below and submit the form, or alternatively download the PDF form.

Referring Dentist

Patient Details

  • Requires antibiotic prophylaxis Requires sedation Non-ambulatory Partially dentate
    Abrason/Erosion Edentulous Bruxist Loss of vertical dimension


  • Complete dentures Immediate dentures Implant overdentures
    Implant fixed bridge Tooth supported crown & bridge Bite Splint
    Partial denture - maxilla / mandible

Notes (teeth)

Radiographs enclosed

  • PAs
  • OPG
  • Bite wings
  • Please return radiographs
Submit form