Paediatric Referral Form

Patient / Guardian Details
Patient Name :*
Guardian Name :*
DOB :
Address :
Post Code :
Phone :
Mobile :*
Email :*
Reason for Referral + Additional Notes
Dental Caries :
- YES
Tooth Number/s :
ACC Details (If Applicable)
Claim Number/ACC42 Number :
Date of Accident :
Referring Dentist Details
Dr. :
Address :
Post Code :
Work Phone :
Email :
Radiographs Taken / Enclosed
PBW’s
- Yes
- No
OPG
- Yes
- No
Please Select Clinic below and email :
Clinic Email*
- Drury : 217 Great South Road, Drury, 2113 (09) 294-7761
- Milford : 2 Dodson Avenue, Milford, 0620 (09) 489-8354
- New Lynn : 14 Delta Avenue, New Lynn, 0600 (09) 826-1664
- Botany : 455/D East Tamaki Road, Botany, 2013 (09) 666-0018