Dentist referral form

Select specialist

Select an endodontist*

Earliest available (recommended)

Dr Ray Sun

Dr Richard Ellis

Dentist first name*

Dentist last name*

Dentist phone*

Dentist email*

Practice name (Optional)

Patient first name*

Patient last name*

Patient date of birth*

Patient email*

Patient street address (optional)

Teeth needing treatment*

Treatment requested*

Consultation

Root canal treatment

Root canal retreatment

Apicoectomy

Other

Please include a clinical description of the problem and any medical conditions.

Referral notes*

Dental anxiety*

Yes

No

Medical conditions*

Please include at least one PA to assist with assessment. You can upload up to six files, jpg, jpeg, png and pdf files accepted.

Upload supporting files*

ACC number (optional)

Date of accident (optional)

414 Lake Road, Takapuna, Auckland 0622

Monday: 8.30am – 5pm

Tuesday: Closed

Wednesday: 8.30am – 5pm

Thursday: 8.30am – 5pm

Friday: 8.30am – 5pm

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