Referrals

Patients may self refer to the clinic by calling 091 399 292.
Dental Surgeons, Medical Doctors, and allied health professionals may refer patients via the form below:
(Please note – a deposit is required to secure all appointments and will be requested by our secretary at the time of booking. This is required to minimize “failure to attend” appointments.)

Referral Form

Patient's Details:Patient's Details:

Name: *

Telephone: *

Email: *

Date of Birth *

Address:Address:

Street Address *

City *

Eircode *

Country: * *

Brief Overview of Presenting Complaint:Brief Overview of Presenting Complaint:

Brief Overview of Presenting Complaint: *

Referrer's Details:Referrer's Details:

Referrer's Name *

Referrer’s Telephone *

Referrer’s Email *

Upload a Radiograph (X ray):Upload a Radiograph (X ray):

Upload a Radiograph (X ray):