Referral to Oral Health Services Tasmania for dental services

Health Practitioners or Agencies Use Only

For any other enquiries please phone 1300 011 013 or email [email protected] to request a form.

Confidentiality Note: The use of your personal information is subject to the provisions of the Personal Information Protection Act 2004.

Referring Agency/GP

Name of Referrer

Telephone

Patient information

Which region of Tasmania does the patient live in?

North

North West

South

Full Name

Date of Birth

Telephone

Health Care Card Number (if applicable)

Pensioner Concession Card Number (if applicable)

Medicare Card Number

Address

Suburb

Postcode

Does the patient need an interpreter?

Yes

What language?

Reason for referral

Please include sufficient information to allow prioritisation of requests.

Medical history

Please list summary.

Current medications

Please list medications or attach health summary.

Attach any documents here:

Maximum 3 files.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

tas.gov.au

Emergency Contacts

Referral to Oral Health Services Tasmania for dental services

Health Practitioners or Agencies Use Only

Referring Agency/GP

Patient information

Reason for referral

Medical history

Current medications

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tas.gov.au

Emergency Contacts

Referral to Oral Health Services Tasmania for dental services

Health Practitioners or Agencies Use Only

Referring Agency/GP

Patient information

Reason for referral

Medical history

Current medications

Find a service

Need to speak to health professional now?

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