Call: (03) 9088 4131 | Level 1 455 Auburn Rd, Hawthorn VIC 3122

Referrals

Need to Refer a Patient?

This page is for dentists, doctors and specialists to refer a patient to see Dr Theresia Sudjalim at Hawthorn Orthodontics, or one of our sister practices South Yarra Orthodontics and Berwick Orthodontic Specialists.

We wish you a warm thank you for trusting your patient’s orthodontic needs with our practice. Dr Sudjalim has over 15 years experience as a specialist orthodontist, so you can rest assured they are in safe hands.

Please complete the form below, and our staff will contact the patient or their parent.

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Refer a Patient

Referral form

Patient details

Orthodontic assessment required for:

Class I
Crossbite
Spacing
Class II
Deepbite
Crowding
Class III
Openbite
Impacted or missing teeth

Dentist details

Submit your records (optional)

Maximum file size: 4MB

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