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Dentist referral

A copy of the information completed below will be emailed to you as a record.

The Braces N Faces Orthodontics welcomes patient referrals from dentists. If you would like to refer a patient to us for orthodontic treatment, please fill in the form below. We will ensure you are kept up-to-date and informed about any treatment plans.
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Fields marked * are required.

Dentist's details

Patient's Details

Do you have a Medicare?**

Second Responsible Party Details

Other than the responsible parties listed above, are there any other individuals or legal guardianship arrangements, in place that require specific consent for the patient to elect treatment and/or who need to be involved in the ongoing management of the orthodontic treatment?*

Emergency Information

General Information

Has the patient had an orthodontic consultation before?*
Has the patient ever had orthodontic treatment?*
Any medical/behavioural conditions, allergies or illnesses?*
Have you had any problems with dental treatment?*
Have any other family members had orthodontic treatment with us?
Are you taking any prescribed medication/s?

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Visit Us

Geelong
92 Derrimut Rd
Hoppers Crossing
VIC
3029
(03) 9748 9224
Directions & Opening Times
Hoppers Crossing
92 Derrimut Rd
Hoppers Crossing
VIC
3029
(03) 9748 9224
Directions & Opening Times