Macquarie Oral and Maxillofacial Specialists

Phone : (02) 9169 3871

E-mail : reception@macquarieoms.com.au

Suite 204 & 501, 135 Macquarie Street, Sydney, NSW, 2000

Preferred Clinician

Dr Peter MouserDr Stuart DeaneDr Anastasia GeorgiouDr Andrew ThorpeFirst Available

Referring Clinician *

Provider Number *

Clinic Name *

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Patient Name *

Patient Date of Birth *

Patient E-mail

Referral Information

Patient referred for *

Wisdom tooth assessment/removalTooth or Implant RemovalOral Pathology / Oral MedicineOrthognathic SurgeryDental implant placementBone grafting without dental implantsFacial pain diagnosis/managementOrthodontic surgery (including anchor plates, expose and bond)MRONJ / ONJ / OsteonecrosisOther

Wisdom teeth to evaluate/remove

All18283848Supplementary molars

Patient Preference

GALAUnsure

Preferred Implant System

Referral Details

Attachments

Patient will be bringing additional records, such as a Cone-beam, with them

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