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Wisdom Teeth Removal
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Doctors Referral Form
Doctors Referral Form
Refer a patient to Dr Michael Schenberg
Patient Details
Title
First Name
Last Name
Street Address
Address Line 2
City
Post Code
Date of Birth
Phone
Request: *
Removal of impacted wisdom teeth
Dental implant/s
Oral mucosal lesion
Removal of tooth/teeth
Sinus lift or alveolar augmentation
Tumour, cyst or other pathology of the jaws, mouth or salivary glands
Other
Clinical Details:
Radiographs have been:
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Attached
Attach Radiograph
Referring Doctor Details
First Name
Last Name
Email
Phone
Provider Number
Street Address of Referrer
Address Line 2
City
Post Code
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