Referrals

Health practitioners, referrals may be performed by either

1. Downloading, printing, completing and returning one of our attached referral forms (Printable Referral Form) OR

2. Using our Online Referral Form below.

If you would prefer a referral pad be mailed to you, please contact our rooms on 9885 5241 and we’d be happy to assist you.

Printable Referral Form

Please print, complete and return vial mail to 1586 High Street Glen Iris VIC 3146 or email to receptiongic@gmail.com.

Patient's Name(Required)

First Last

Patient's Address(Required)

Street Address City State Post Code

Patient's Date of birth(Required)

Patient's Phone(Required)

Reason for Referral(Required)

Oral mucosal lesion/swelling

Temporomandibular disorder

Facial pain

Intraoral pain

Altered oral sensation

Unexplainable toothache

Assessment of radiograph

Xerostomia

Other

Attached Files(Required)

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB, Max. files: 10.

Please upload any relevant clinical photos or radiographs below. If larger then 5MB per file, please instead email to receptiongic@gmail.com

If other, reason for referral(Required)

Clinical Details(Required)

Referring Clinician's Details(Required)

First Last

Clinician Type(Required)

Email(Required)

Address(Required)

Street Address City State Post Code

Phone(Required)

This field is for validation purposes and should be left unchanged.