Specialist Referral Form

At Smileworks, we endeavour to work closely with our referring partners to provide our expertise. Please fill up the online patient referral form. It will take less than 5 minutes. You will automatically receive a copy of this referral form by email upon submission. We will contact the patient to arrange an appointment and keep you informed of the patient’s progress.

    Patient's Details


    Preferred Contact Number*:

    Email Address*:

    Reasons For Referral*

    Reason for Referral:

    Preferred Prosthodontist

    Periodontal Treatment:

    History of Past Periodontal Treatment:
    Non-surgical periodontal therapy.

    When was last scaling performed?

    Surgical periodontal therapy

    Additional Clinical Notes:(if any):

    Patient's Chief Complaint
    Provisional Diagnosis

    Preferred Orthodontist


    Type Of Treatments:

    Restorative Plan

    Upload the latest relevant radiograph/photograph if any. Our clinic will be in touch with you if we need more information from you

    Doctor's Details

    Referring Doctor*:


    Preferred Contact Number

    Email Address