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Practitioner Referral

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Referring Practitioner:

Please fill out the following form.

Profession / Specialty:
Preferred method of contact:

Patient Details:

Patient date of birth:
Day
Month
Year
Reason for referral (please select all that apply)

RELEVANT CLINICAL & DENTAL INFORMATION

Has dental/odontogenic pathology been investigated where appropriate?
Current occlusal splint / night guard?:

IMPORTANT MEDICAL INFORMATION

COMMUNICATION & COLLABORATIVE CARE

Would you like a clinical update following assessment?

Collaborative Care

Hamilton TMJ Solutions aims to complement—not replace—the patient's existing dental and medical care. Where further dental assessment, splint consideration, investigation or specialist opinion is indicated, the patient will be directed back to their existing practitioner wherever appropriate.

PATIENT CONSENT

I confirm that the patient is aware of this referral and has consented to their personal and relevant clinical information being provided to Hamilton TMJ Solutions for the purpose of assessment and treatment.
The patient has consented to Hamilton TMJ Solutions communicating relevant assessment and treatment information with me as the referring practitioner.
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