Specialist Referral ClinicianFirst AvailableDr Prashanth DhanpalLocation *PymbleTamworthLithgowPatient Name *Date of BirthGenderMaleFemale-Phone NumberAddressParents NameMedical HistoryTreatment to DateReason for ReferralCaries/CavitiesAbscessTrauma/FractureOrthodonticEnamel HypoplasiaOver-Retained TeethSupernumeraryOtherTreatment Required:RestorationStainless Steel CrownFissure SealantPulpotomyExtraction/Surgical RemovalMinor Oral SurgeryObjectives of ReferralOpinion OnlyOpinion & management of Specific ConditionGeneral CareRadiographs Attached:BitewingPeriapicalOcclusalOPGCephalogramTomogram/CTReferrer Name *Referrer Address:Email *Phone/Mobile Number *File Upload OneFile Upload TwoFile Upload ThreeFile Upload FourFile Upload FiveFile Upload SixWebsiteSubmit