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Dentist referrals

Name: Straight Smiles
Telephone: (03) 5941 5188

At Straight Smiles, we love working with our fellow dental professionals to improve our patients’ smiles. If you would like to refer a patient to us for orthodontic treatment, please fill out the form below.

We will email you a copy of the completed information for your records – and keep you informed about any treatment plans for your patients.

Dentist's Details

Fields marked * are required.

Dentist Name*

Practice Name

Dentist Email*

Dentist Phone*

Practice Address*

Patient Details

Patient First Name*

Patient Last Name*

Parent or guardian's name*

Patient Email*

Patient Phone*

Patient Address*

Preferred Practice Location

Mulgrave

Pakenham

Drouin

Reason for referral*

Send Us Your Photos

For any photos, xrays or additional information you wish to submit alongside this referral, please upload here. Accepted file types: jpg, gif, png, pdf (up to 5 files only; max file size 10MB)

Upload Here