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