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

Click Here to Download Referral Form

Online Referral Form

Patient Details

Reason for Referral
Oral mucosal lesion/swellingTemporomandibular disorderFacial painIntraoral painAltered oral sensationUnexplainable toothacheAssessment of radiographXerostomiaOther

Attached Files
Please upload any relevant clinical photos or radiographs below. If larger then 5MB per file, please instead email to

Clinical Details

Referring Clinician's Details