For doctors

Referral for surgical opinion / management

If you would like to refer a patient for a surgical opinion or management, please complete our referral form or download and forward it to us. We will contact your patient to make an appointment.

Patient details

Title

Given Name

Surname

Date of Birth

Home Address

Suburb

Postcode

Phone Number

For consultation and treatment regarding

Wisdom Teeth Removal

Yes

Tooth Extraction – including the surgical removal of impacted and infected teeth

Yes

Dental Implants

Yes

Corrective Jaw Surgery (Orthognathic Surgery)

Yes

Facial Injury

Yes

Pathology – mouth / jaws

Yes

Please provide any further information or medical history relevant to your referral:

Attach OPG / X-ray / Photo:

Radiographs

Already taken and available online at:

Will email copy

Yes

Please take appropriate imaging in your rooms

Yes

To book an appointment, please call us on 03 5229 3200

Referred By:

Doctor's Name

Practice / Clinic Name

Provider Number

Address

Suburb

Postcode

Phone Number

Email Address

Authorisation:

Sign Here

Clear Signature

Date

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Please fill out the form below to book a consultation at Precision OMS’s Geelong offices.

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Email Address

Phone Number

Message

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Referral for surgical opinion / management

Patient details

For consultation and treatment regarding

Radiographs

To book an appointment, please call us on 03 5229 3200

Referred By:

Authorisation:

Your form has been successfully submitted

Get in touch