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(02) 9686 8018

About Us
- Our Team
- Practice Gallery
Dental Implants
Oral Surgery
Periodontics
Sleep Dentistry
Patient Information
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- Payment Plans
For Doctors
- Dentist Referral Form

(02) 9686 8018

About Us
- Our Team
- Practice Gallery
Dental Implants
Oral Surgery
Periodontics
Sleep Dentistry
Patient Information
- First Visit
- Payment Plans
For Doctors
- Dentist Referral Form

Menu

About Us
- Our Team
- Practice Gallery
Dental Implants
Oral Surgery
Periodontics
Sleep Dentistry
Patient Information
- First Visit
- Payment Plans
For Doctors
- Dentist Referral Form

Dentist Referral Form

1. Who is the referral for?

Doctor

Dr Patty Chou (Periodontist)

Dr David Willis (Dental Surgery)

Dr Rohan Rodricks (Periodontist)

Either

2. Referring Practitioner

Name*

First Last

Email*

Phone*

Date

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

3. Patient Details

Name*

First Last

Email*

Mobile*

DOB

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Preference*

Patient to call

Please contact patient

4. Referral Details

Periodontics

Periodontal Management / Regeneration

Gingival Graft

Orthodontic Exposure / Bond

Fraenectomy / Pericision

Crown Lengthening

Dental Implants

Implant Site(s)

Peri-implantitis

Implant Site(s)

Oral Surgery

Wisdom Teeth

Extraction(s)

Pre-prosthetic Surgery

Do you have Radiographs?

Yes

No

How are Radiographs being sent?

Sent With Patient

Mailed

Emailed

Comments / Relevant Medical History

Δ

Download Our Referral Form PDF

We welcome new patients whether you’ve been referred by your Dentist or would like to book with us directly.

Please call us for an initial consultation with Dr. Willis or Dr. Chou or Dr. Rodricks.

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Lemon Grove Shopping Centre Shop 8, 427 Victoria Avenue Chatswood, NSW 2067

(02) 9686 8018

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Opening Hours

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

9:00 AM - 5:00 PM
9:00 AM - 5:00 PM
9:00 AM - 5:00 PM
9:00 AM - 5:00 PM
9:00 AM - 5:00 PM
By Appointment Only
By Appointment Only

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