Refer a Patient

Dr Josephine Bayliss-Chapman welcomes referrals for periodontal assessment and treatment. Patients will always be returned to the care of their referring dentist for ongoing maintenance.

Referring Dentist Information

Referring Dentist Name *

Referring Dental Practice *

Reason for Referral

Primary Reason *

Please specify

Additional Information

Patient Details

Patient Name *

Date of Birth *

Address

Phone Number *

Email Address

Photos & X-rays

Upload clinical photos or radiographs

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Drag files here or click to browse

JPG, PNG, PDF, or DICOM • Max 10MB per file

Preferred Clinic

Which practice should the patient attend? *

By submitting this form, you confirm you have obtained consent from the patient to share their details for referral purposes.