Maxillofacial online referral form for Country Patients

We have created this online referral form to make your life easier. You can make your life even easier by clicking on the create an account button below which will remove step 1 from future referrals. We will remember your details for next time making your next referral even easier.

Quick referral letter upload

Use this form to upload a scanned referral letter in JPG, Word (doc/docx) or PDF format.

Supported files: doc, docx, pdf, jpg
Step 1 of 4

Referring Information

IMPORTANT: This form is to be completed in full by a registered dental and / or medical practicioner to be eligible for Medicare rebate for consultation.