Dentists Referral Form Please fill in the online form below, or if you prefer download and print the from as a pdf – click here. Referring For: Dental implants, sinus lifts & block graftingI.V. and Inhalation sedationOral & third molar surgeryAesthetic / cosmetic and advanced restorative dentistryPeriodontal surgery & microsurgeryEndodontics & micro-endodonticsNervous patient management Dentist Details Please write your full name above including your GDC Number. This will act as an electronic signature. Patient Details The Patient is Experiencing: Failed bridgeworkUnsightly spacesLoose denturesDifficulty chewingPeriodontal problemsFailing post crown I would like to arrange a joint treatment plan for this patient I would like to do the restorative work on the implant(s) Select a file to upload maximum file size 10mb Please leave this field empty. If you wish to refer for CBCT scanning please go to this page CBCT Referral Form.