Patient Referral Form

Online Referral Form for Dr Tim Manzie

APPOINTMENT LOCATION

Location of preferred appointment

Chris O'Brien Lifehouse Hospital (Camperdown)Shoalhaven Surgical Specialists (Nowra)Eastern Suburbs Oral and Maxillofacial Surgery (Bondi)Next available

PATIENT BEING REFERRED

First Name *

Last Name *

DOB *

Phone Number *

Email Address

Patient Address

Medicare Number

Private Health Insurance

YesNoUnsure

Suburb

Postcode

State

DETAILS OF REFERRAL

Urgency *

UrgentRoutine

Pathology

intraoral soft tissue lesionbony lesion/cystskin lesionneck lump

Extractions

Wisdom Teeth (please specify below)Supernumerary / impacted teethOther (please specify below)

Details of extraction (additional information)

Implants

Implant/s (please specify below)Bone graft / sinus lift

Does the patient have

Intraoral scanStone/study modelsNil

Location of implants (if necessary)

What is your preferred implant system?

Facial Trauma

AcuteDelayed (> 2 weeks)

Clinical Notes

IMAGING

Details of Imaging Provider

You may upload any imaging files here

Browse

You may upload additional files here

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For additional imaging or to share files/links, please email admin@drtimmanzie.com.au

REFERRING DENTIST / DOCTOR

Name

Practice

Practice Location

Provider Number

Email

Date of Referral *

Signature of Referring Doctor *

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