Banner Small 2

 

 

Online Referral Form

Patient Details

Patient Name *
Contact Number *

Referal Details

1. Indicate tooth
to be treated.
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
2. Indicate Additional
Work Required



3. Repeat for each
additional Tooth
Required
Core Build up?
Core Build up?
Remarks
Attach X-ray Image

Dentist Details

Name *
Address *
Contact Number *
Email
How would you like your report sent back to you?
Via Email Via Mail
 

Meet
the Staff

Dr. Seung Tae Kim graduated from Otago University, New Zealand in 1992 with Bachelor of Dental Surgery..

Read More

55C Lower Heidelberg Rd, Ivanhoe VIC 3079

 

Patient
Information

Your first visit will consist of a detailed examination and consultation explaining your diagnosis and..

Read More

p. +61 3 9499 9088

 

Referring
Dentists

We are commited to providing the best service possible for your patients as well as for the referring professionals..

Read More

f. +61 3 9499 7156