Patient referral | Sydney Implant and Periodontal Care

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Order Number

Patient's Details

Let us know how to get in touch with the patient.

Patient's First Name *

Patient's Last Name *

Patient's Email Address

Patient's Phone Number

Patient's D.O.B

Patient is being referred for evaluation of:

(select one or more)

Periodontal disease

Implant placement

Bone grafting

Implant complications

Extraction

Crown lengthening

Gingival recession

Exposure of tooth

Other

More information on referral:

I will be forwarding the following radiographs (Dated):

Radiograph

OPG

PA

BWs

CBCT

Radiograph date:

Referred by:

Referrer's Name *

Referrer's Phone Number *

Referrer's Email *

Upload relevant files: letters of referral, x-rays, other imaging etc.

(Accepted file types: jpg, pdf, DICOM formats)

Comments / Questions

Location

Sydney Implant & Periodontal Care
Level 12, 99 York St.
Sydney, NSW 2000

Contact

t: (02) 9279 4867
f: (02) 9279 4866
info@perio-implants.com.au

Sydney Implant and Periodontal

Hours

M - F : 8am–5pm
Sat : Closed
Sun : Closed