Referral Form

Patient Details


Patient Details

Reason for Referral

Have Radiographs been taken and emailed?

Referrer Details

Thanks you for choosing to refer your young patient to North Lakes Paediatric Dentistry.

Dr Nymphia and her staff aim to work along with you to provide quality specialist dental care for children in the Kawana, Maroochydore, Caloundra, North Lakes, Kilcoy, Kingaroy, Caboolture, Deception Bay, Bribie island, North Brisbane, Glass House Mountains,, Sunshine Coast and Hervey Bay area.

We make every effort to ensure that appointments are available within a suitable timeframe to enable treatment to suit the child’s individual needs. All emergencies such as dental trauma or facial swellings are top priority.

In case of emergencies, please call us on 07 3495 0250 or email

For other referrals, we recommend you ask parents to contact us for an appointment. Referrals can be sent by the following simple options:

If you would like a referral pad sent to you, please contact us.

  • Complete the referral form and submit online. Or you could print, scan and email it. Complete a referral pad form and send it with your patient

Please include: Previous records/previous radiograp

North Lakes Paediatric Dentistry would like to do its part in making Australia “greener” by going paperless. We recommend electronic correspondence and we will email all our patient reports back to your practice email.

For Medical Practitioners and other allied health professionals

We welcome all referrals from general medical practitioners, paediatricians, ENT surgeons, speech pathologists and other allied health professionals.

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