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Submit a referral

Patient information:

Patient full name

Date of Birth

Mobile


Clinical details:

Clinical details related to the referral

Step 1: Select the clinical service you are referring for.

Unsure?
Start with TMJ Therapy to help settle symptoms and assess jaw/spine mechanics before proceeding to splint or dental sleep therapy. For our Dental Referrers, patients will be referred back to you for splint or sleep device therapy unless you select those below.
Step 1: Select the clinical service you are referring for.

Step 2: For Dental Referrers ONLY - Do You Consent to Our Dental Team Being Involved If Required?

If you did not tick “TMJ Dental Assessment and Occlusal Splint Therapy” or “Dental Sleep Medicine Assessment” above, but are happy for our TMJ/Sleep Dentists to be included in care if clinically appropriate, please indicate below.
Step 2: For Dental Referrers ONLY - Do You Consent to Our Dental Team Being Involved If Required?
Note: Our TMJ/Sleep Dentists are only involved with your patient’s care if you specifically refer to them above or opt in here.

Referrer details

Your name

Your email

Clinic Name

Clinic Address

Please upload any relevant files related to the referral


Thank you for your kind referral and entrusting us with your patient's care.