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Affinity Periodontics & Implant Dentistry

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Online Referral Form

Online referral form

Thank you for referring your patient to Affinity Periodontics & Implant Dentistry. Please complete the form below so that we may appropriately appoint your patient. Thank you.

Please direct my referral to:

The first available periodontist

Dr William Cho

A/Prof Melinda Newnham

Ingrid Sawyer OHT for periodontal maintenance

Jessica Buhagiar OHT for periodontal maintenance

Affinity to contact the patient

Patient to contact Affinity

Clinician Details

First Name

Last Name

Practice

Clinician Email

Phone Number

Practice Address

Address Line 1

Suburb

City

State

Postcode

Patient Details

First Name

Last Name

Date of Birth

Email

Phone Number

Address

Address Line 1

Suburb

City

State

Postcode

Reason For Referral

Select all that apply

Periodontal Management

Dental Implant Placement

Crown Lengthening

Recession/ Mucogingival

Peri-implantitis

Second Opinion

Other

Further Information:

Attachments:

OPG

Periapicals/ Bitewings

CBCT

Clinical Photographs

Attachments to be sent via WeTransfer

To be emailed to Affinity Periodontics

This patient has consented to the transfer of their confidential information to Affinity Periodontics & Implant Dentistry.