Referral for Dr Andrew Thorpe
Clinician and Patient Information
Referring Clinician
*
Provider Number
Clinic Name
*
Clinic E-Mail
*
This e-mail will receive a copy of your referral
Clinic Address
Please provide if we have not worked with you before
Patient Name
*
Patient E-Mail
Please enter either e-mail, phone, or both
Patient Date of Birth
*
Patient Phone Number
Send a copy of this referral to the patient
(requires patient e-mail)
Preferred Location
*
Macquarie St (Sydney CBD) - Macquarie Oral And Maxillofacial Specialists (501/135 Macquarie St, NSW, 2000) - 9169 3871
Erskine Park (within Erskine Park Dental, Shop 18 Erskine Park Shopping Centre, Swallow Dr, Erskine Park NSW, 2759) - 9670 4141
Other
Other Location
Referral Information
Patient referred for
*
Wisdom teeth assessment / removal
Orthodontic Surgery
Tooth or Implant removal
Dental Implant Placement
Bone grafting without dental implants
Pathology
Facial pain diagnosis / management
Pre-prosthetic Surgery
Gingival grafting
Assistance with Uncertain Diagnosis
MRONJ / ORN / Osteomyelitis
Medically Complex Patient
Medicolegal Assistance
Other
Wisdom teeth to evaluate / remove
All
18
28
38
48
Supplementary molars
Patient Preference
GA
LA
Undecided
Preferred Implant System
Referral Details
Please tick this box if you would prefer that I call you prior to seeing this patient
Referring Clinician Contact number
Medical History (Optional)
Important Medical History
History of Bisphosphonates / Prolia / Fosamax
Head and Neck Radiation
Heart Disease or Heart Attack
Stroke History
Blood thinners
Diabetes
Type 1
Type 2
Uncertain
Blood Thinners
Apixaban (Eliquis)
Dabigatran (Pradaxa)
Rivaroxaban (Xeralto)
Aspirin
Clopidogrel (Plavix)
Warfarin
Other
Any Additional Medical Information
Attachments
Please tick here if the patient will be bringing additional records, such as a Cone-Beam, with them
Radiographs / Images / Letters to Attach (30mb total limit)
Browse
Additional file if required
Browse
2nd Additional file if required
Browse
3rd Additional file if required
Browse
4th Additional file if required
Browse
My apologies, however this is needed to minimise spam bots
*
Please wait, files are uploading..
Submit