Referral Form

Thank you for referring your patient for specialist endodontic treatment with Dr Christine Premdas-Rogers. With the aim of making the referral process as streamlined as possible, you can refer your patient online, securely, using one of the following two options:

Option 1:

Complete the online form, below.

Option 2:

Download the form (PDF) here, complete and upload it securely via the file uploader at the bottom of this page. This ensures patient confidentiality. Please do not email the form, as the data is not encrypted.

Option 1: Online form

Referral information

 

Verification

 

Option 2: Upload your completed referral form

 
 

Verification