Referral Form
(For Referring Dentists Only)
Leave this field blank if you are human:
Step 1: Select Branch Location
(required)
Penang (PG)
Kuala Lumpur (KL)
Referring to Specialist :
(required)
Please choose the specialist(s) that you want to refer to
Orthodontist - Dr Chay Siew Han (May)
Orthodontist - Dr Kho Aik Jin (Eugene)
Periodontist - Dr Freeda Woon
Endodontist - Dr Travis Tan Huan Chang
Restorative - Dr Brenda Sim
Associate Dentist - Dr Chan Ying Ying
Restorative - Dr Lee Yan Ming
Orthodontist - Dr Priyanka Sriraman
Orthodontist - Dr Nabilla Mohd Shukor
Oral Surgeon - Dr Batmaraj Rawisandran
Paediatric - Dr Lim Sing Ying
Paediatric - Dr Ilham Wan Omar
Special Care Dentistry - Dr Aminda Faizura Omar
Reason for Referral :
(required)
Referring Dentist Name :
(required)
Referring Dentist Clinic :
(required)
Referring Dentist Email :
(required)
Date :
To refer the patient back to the referring clinic (for all other treatments) after completion of the indicated treatment.
(required)
Yes
No
Attachment
Send
or
Download Blank Physical Referral Form
or
Download Physical Referral Form (With Data)
Penang
KL
