Online Referral Form

Refer your patient to Dr Gloria at The Prosthodontic Practice by completing the form below. Our team will contact the patient to arrange an appointment and keep you updated on their treatment progress.

If you have any questions about our services, please contact our office.

Email: info@drgloriahsu.com.au

Patient Information

*First Name

*Last Name

*Date of Birth

*Contact Number

*Address

Clinical Information

*Patient Concerns

Aesthetic issues

Functional issues

Pain / discomfort

Other

*Scope of Treatment

Conventional crown & bridge

Dental implants

Removable dentures

TMD management

Mandibular advancement splint

Other

Relevant Medical History

Additional Information

Attach a File

Upload any relevant X-rays, images or documents (up to 4 files). Alternatively, email your file to info@drgloriahsu.com.au

Referring Clinician Details

*Clinician's Full Name

Contact Number

*Email Address

Please specify the best email for sending reports and patient correspondence.

*Name of Practice

*Practice Address

Date of Referral

I confirm that the above patient has consented to this referral and has given permission to share their contact information and relevant medical history for the purpose of specialist treatment.

Your trusted Prosthodontist servicing the Gold Coast and beyond

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Contact

info@drgloriahsu.com.au

(07) 5644 5000

Online Referrals

Dr Gloria Hsu is operating at:

The Prosthodontic Practice
Suite 10, Level 6, Premion Place

39 White St
Southport QLD 4215

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