Thank you for referring to Tooth Town. We will contact the family directly to arrange their appointment, and send you a copy of this referral for your records.
Patient details
Patient name
Date of birth Patient address — if you have it Parent or guardian name — so we greet them by name when we write back Parent email address — if you have it Parent mobile Referral details
Appointment preference — tick any that apply First Specialist Appointment Available Dr Maryam Ghafournia Dr Steve Kazoullis Dr Helen Fung Early interceptive orthodontics Myofunctional therapy (Michelle Sankey) Special Needs Dentistry (Dr Candy Fung)
Reason for referral — tick any that apply GA / Behaviour Management Caries Abscess Trauma Tongue Tie Early Interceptive Orthodontics Airway Management Special Needs
Medical history, any additional information Objectives of referral Opinion, management of the above condition and provision of ongoing care Opinion, management of the above condition with the patient returned to you for ongoing care
Radiographs enclosed Yes, please see attached files No, none available No, radiographs/photos emailed to info@toothtown.com.au No, please email signed Release of Records form Please access OPG via Dental Diagnostics portal Please access OPG via QXR portal Please access OPG via QScan portal Please access OPG via i-Med portal Please access OPG via Exact portal Please access OPG via Citiscan portal
Attach files — radiographs, photos, a letter. Up to 8, 10MB each. Do you require a record of release form completed to transfer any records not already provided? Yes No
Your details
Referring clinician
Provider number — if you have it to hand Contact number Practice name Practice address — if you would like it on file Email address — a copy of this referral is emailed here for your records Would you like a copy of this referral emailed to the parents? Yes No
Send the referral Anything you send us is held in the child’s record and seen only by the team caring for them.