Form For Referring Doctors

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Oral & Maxillo-Facial Surgeons

Please select 1 of the following (required):
Andrew A. C. HeggieKevin RuljancichJocelyn M. ShandJameel KaderbhaiNo preference

Practices

Please select 1 of the following (required):
Level 6/120 Collins St, Melbourne VIC 300018 Scholar Drive, University Hill, Bundoora, VIC 3083428 Riversdale Road, Hawthorn East, VIC 312317 Wantirna Road, Ringwood, VIC 3134

Telephone 03 90 888 666 for all practices

Patients Name (required):

Patients DOB (required):

Patients Address (required):

Patients Telephone (required):

Patients Mobile (required):

Reason for Consultation (required):
Wisdom TeethImplantJaw (Orthognathic surgery)PathologyOther

Referral Notes (required):

Post Implant Surgery

The implant will be restored by myself (required): YesNo

The implant will be restored by a different practitioner (required): YesNo
If yes, please enter the different practitioner's name:

Radiographs

Type of Radiograph (required):
OPGPALateral CephC.T. ScanOther

Status of Radiographs (required):
Patient bringing to consultationReferring doctor to send in mailReferring doctor to attach radiograph below or to e-mail reception@melbourneoms.com.au

Upload Radiographs here:
File size limit 5mb
File types accepted gif, png, jpg, jpeg, pdf

Referring Doctor's Name: (required)

Referring Doctor's Email: (required)

Referring Doctor's Provider Number: (required)

Referring Doctor's Address: (required)

Referring Doctor's Phone Number:

For directions, please refer to the maps on our website: Main Office CBD | Bundoora | Hawthorn East | Ringwood

Reminder: This is a referral form only. To make an appointment please advise the patient to call 03 90 888 666 where our staff can assist.

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