for dentists

PATIENT REFERRAL FORM

Here at Rai, we specialise in Complex Restorative Dentistry, Specialist Oral Surgery and Dental Implants.

If you’d like to refer one of your patients to us, please fill out the form below and we’ll be in touch.

Referring Dentist

Practice Details

Referring Patient Details

Reason for referral

Upload x-rays and pictures of the case in the following formats: jpeg, jpg, gif, png Up to 5 images permitted, max size 3MB per image.


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