Geans Dental - Specialist Referrals

At Geans Dental we welcome referrals
for Oral Surgery and Sedation Services.
Please submit your referral by
completing the form below.

Your Patient’s Details

Patient’s Name

Patient’s Date of Birth

Patient’s Gender

Patient’s Address

Patient’s Home Phone

Patient’s Mobile Phone

Patient’s Email

Has the Patient previously attend Geans Dental?

Your Patient’s Medical History

Tell us about your Patient’s Medical History

What medications does your Patient take?

Treatment Required for your Patient

Does your Patient require

Are you attaching Radiographs?

Tell us about the type of Treatment your Patient requires

Does your Patient require Intravenous Sedation?

In your assessment, is the referral urgent?

Have you discussed the Postoperative treatment options with your patient?

Referring Practitioner’s Details

You are the

Your Name

Name of your practice

Address of your practice

Referring Practitioner’s Email

Referring Practitioner’s Telephone

Please Tick the following Declarations :

The patient understands the need for a consultation before treatment and that it does not indicate that treatment will be undertaken and the patient may choose to be referred for further treatment e.g. GA, following consultation The patient has understood the treatment plan and need for referral including future treatment needs I understand this patient may require further treatment/investigations if deemed necessary following the consultation and I will be informed of this if this is the case I have informed my patient of the fees and 100% cancellation charge will be made on any cancellations made within 48 hours

SpecialistReferrals

At Geans Dental we welcome referrals for Oral Surgery and Sedation Services. Please submit your referral by completing the form below.