Referral to Oral Health Services Tasmania for dental services Breadcrumb Home Health Topics Dental Health Dental Health Information and Education For Health Professionals Referral To Oral Health Services Referral To Oral Health Services Tasmania For Dental Services Listen Print Main navigation Dental health Learn about dental health Dental Health Services Dental health programs and initiatives Dental health information and education for health professionals Referral to dental health services Refer a child (Lift the Lip) Refer a pregnant woman (Healthy Smiles for Two) Referral to Oral Health Services Tasmania for dental services Lift the lip screening and referral pathway tool Tasmania denture care scheme Emergency Dental Scheme Regulation, policy and guidelines for dental health You must have JavaScript enabled to use this form. Health Practitioners or Agencies Use Only For any other enquiries please phone 1300 011 013 or email [email protected] to request a form. Confidentiality Note: The use of your personal information is subject to the provisions of the Personal Information Protection Act 2004. Referring Agency/GP Name of Referrer Telephone Email Patient information Which region of Tasmania does the patient live in? North North West South Full Name Date of Birth Telephone Health Care Card Number (if applicable) Pensioner Concession Card Number (if applicable) Medicare Card Number Address Address Suburb Postcode Does the patient need an interpreter? Yes No What language? Reason for referral Please include sufficient information to allow prioritisation of requests. Medical history Please list summary. Current medications Please list medications or attach health summary. Attach any documents here: Maximum 3 files.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.