Dentist referral form

Thanks for your referral. Please complete the form below with the patient's details and the reason for referral, and we'll be in touch.

Referral details

Your name

Your contact details (phone and/or email)

Orthodontist preference

Dr Russell Lovatt Dr Chrissy Bailey No preference

Patient

Patient name

Name of parent/caregiver (if applicable)

Patient date of birth

School (if applicable)

Patient/caregiver contact details (address, phone, email)

Clinical information

Reason for referral

Additional comments

X-rays or referral letters? Please email them to info@chchortho.co.nz.

We use this information only to process your referral.