Patient Referral Form

To*: Dr LIM Kian Chong, Gerald

From:
Last Name* Other Names*

E-mail address*:

Patient Referred:
Last Name* Other Names

Patient Contact No:

Referred for: Consultation Root Canal Treatment

Surgical Endodontics Tooth Trauma Management

Implant Prosthodontics Others

Relevant Medical History:

Details of Referral*:

* Required fields have to be filled in otherwise the form will be rejected!

Please send any relevant radiographs with the patient. This will be returned to you. Digital radiographs can be sent as JPEG attachments via e-mail. Please compress radiograph files using winzip, otherwise, the file may be too large to send.