Implant Referral Form

Implant Referral Form
Date of referral*

DayMonthYear
Priority*
Patient Information
Name*

PrefixFirst NameLast Name
Date of birth*

DayMonthYear
Phone number*
Format: (000) 000-0000.
Email
Patient's existing and pre-existing risk factors*

Gum diseaseRisk of osteonecrosisProlia injectionReceived or currently under a radiation therapyTaking anticoagulant medicationReaction to anaestheticDementiaAnxious patientOther
For Consultation and Care Regarding
Our procedures*

Dental implant/s (please specify the site/s on the clinical notes below)Full-arch implant or All-on-XExtraction & immediate implantationSinus liftExtraction & socket preservationBone grafting, ridge or site developmentAll-on-4Implant removalManagement of complicationOther
Does the patient need bone grafting?*
Preferred implant system*

StraumannAstra-Tech EV (Dentsply)Leave choice to the surgeon
Was there a specific practitioner you are referring to?*
Clinical notes to our specialist*
Supporting radiography record*
Please upload patient's radiography record i.e., PA, OPG, Lat-Ceph xray, CBCT, or clinical photo- for CBCT scan, please send via WeTransfer to reception@macarthur.com

Cancelof
Referring Doctor Information
Name*

PrefixFirst NameLast Name
Clinic or practice name*
Provider number*
Address*

Street Address

Street Address Line 2

SuburbState

Postcode
Contact number*
Format: (000) 000-0000.
Best email correspondence*
Postcode*
If you have not referred to Macarthur Surgical Centre previously, we would like to know how did you hear about us?

Peer recommendationProfessional event or conferencePractice representative visitInternet search or GoogleLocal business directoryOnline article or blogSocial media (e.g. LinkedIn)Other
Should be Empty:

Implant Referral Form

Patient Information

For Consultation and Care Regarding

Referring Doctor Information