Dental Specialist Referral Johor Bahru | Dental Refer Case Johor Bahru | Dental Specialist Johor Bahru

Refer a Case

Patient Details

Patient’s Name*

ID Number*

Patient’s Contact Number*

Medical History / Allergy*

Treatment Rendered*

Referring Dentist Details

Dentist’s Name*

Dentist's Contact Number*

Email Address*

Clinic Name*

Clinic Address*

Referral Details

Services*

Other

Enter the name of the relevant clinician to refer your patient to (if known)

Reason for referral*

To send back the patient to referring clinic after the indicated treatment completed Yes No

To send the patient report by email Yes No

Attached with patient's relavant documents

Dental Partners :