Online Healthcare Provider Patient Referral Form

Please complete this form to refer your patient to Hobart Special Care Dental

Patient Details

Title

MrMrsMsMissOther

First Name *

Last Name *

Patient Date of Birth *

Patient Contact Number *

Patient Email Address

Patient Address *

Street Address *Street Address line 2

City *

State / Province *

Postal / Zip Code *

Country

Patient Consent Information

Who makes your healthcare decisions? *

SelfLegal guardianSubstitute decision maker

Please state the name of the patient's legal guardian or substitute decision maker

First Name *

Last Name *

Please state their relationship to the patient? *Legal guardian, parent, sibling, friend

Please provide the legal guardian's or substitute decision maker's phone number *

Please provide the legal guardian's or substitute decision maker's email address

Referral Information

Reason for Referral *(e.g., dental assessment pre- & post-medical treatment including cardiac surgery, radiotherapy, antiresorptive therapy; deteriorating dentition in the context of complex medical history)

Medical History *(e.g., medical conditions, medications, allergies)

Dental History *(clinical records, relevant information)

Other relevant information(e.g., wheelchair access)

Please upload relevant files

Browse

(e.g., written referral, medical summary, dental records including relevant radiographs etc)

Urgency of Referral

Please indicate the urgency of this referral *

Urgent (within 1-2 weeks)Semi-urgent (within 4-6 weeks)Non-urgent (within 12 weeks)

Referrers Details

Referring Provider's Name

First Name *

Last Name *

Referrer Address *

Street Address *Street address line 2

City *

State / Province *

Postal / Zip Code *

Country

Referring Provider's Phone Number *

Referring Provider's Email Address *

Outcome of referral *

Assessment and management of the specific condition, with follow-up arranged for the patient to return to referrer for ongoing careManagement of the specific condition and continuation of care at Hobart Special Care Dental

Please wait, files are uploading..