Online Referral Date of Referral * MM DD YYYY Priority Routine Urgent Preferred Location Albury Griffith Wangaratta Patient Details * First Name Last Name Date of birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email Phone * (###) ### #### Referred for Wisdom teeth removal Dental extraction(s) Dental implant(s) Oral pathology Sinus lift Bone graft Torus removal or alveoloplasty Facial skin lesion Orthognathic surgery Facial reconstruction Oral medicine Supernumerary Frenectomy TMJ consultation Apicectomy Tooth exposure/bonding Oral cancer Other Clinical Information Radiograph / Radiology Not applicable With patient To be emailed / attached Anaesthetic Choice Local anaesthesia Green Whistle (Methoxyflurane) General anaesthesia Intravenous Sedation Referring Practitioner * First Name Last Name Title Dr Prof Mr Ms Mrs Provider number * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email Thank you!
