Shirley Park Dental

357 Addiscombe Road

Smile 4 U

10 Belmont Parade

Referral Form

Referral Procedure


When we receive your referral request after you submit the form below; your patient will be contacted to make an appointment. The initial consultation will take 30 minutes and will consist of medical and social background information, to assess the extent of the patient’s problem. All the options and choices open to the patient will be discussed in detail with patient. If it is a particularly complex case a further visit may be necessary as well taking study models or even a CT scan at the practice.

Simply fill in your patients details below When the patient is ready to proceed with treatment we will make all the necessary appointments. During treatment is always reminded of the necessity of continuing to visit you for their general dental regular and treatment.

Referring Dentist Details

Referring Dentist Name *

Your Patient Details

Patient Name *

Radiographs & Scans


You can attach your patients radiographs & scans below. Alternatively you can send them with your patient.

Acceptable file types: jpg, jpeg, png, gif, pdf, doc, docx, ppt, pptx

Maximum file size: 3mb

review bg

“I attended today to have a large filling sorted out. I am extremely anxious with dentist visits, but the time the dentist took to reassure me and check on me throughout the procedure was fantastic and made all the difference for me.”


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