Online Referral Form(For Referring Dentists Only) Patient Name * Patient Contact Number * Referring to: * --Please choose the specialist(s) that you want to refer to-- Dr. Bryon Ong (Endodontist) Dr. Yeoh Oon Take (Prosthodontist) Dr. Lee Chee Wei (Oral Maxillofacial Surgeon) Dr. Joan Lim (Esthetic Dentist & Restorative Specialist) Dr. Lim Zhi Wei (Orthodontist) Dr. Sarene Saw (Endodontist) Dr. Lew Pit Hui (Periodontist) Dr. Khor Swee Ting (Pediatric Dental Specialist) Dr. Goh Yet Ching (Oral Medicine Specialist) -- Others -- Reason for Referral * (Please indicate the tooth / area of concern) Referring Dentist Name * Referring Dentist Clinic * Referring Dentist Email * Date MM DD YYYY To refer the patient back to the referring clinic (for all other treatments) after completion of the indicated treatment * Yes No Attachment FileField; MaxSize=10000KB; Multiple; addText=Upload_Your_Files We will keep you posted after we have seen the patient. Thank you for your referral! Click To Download Physical Referral Form
