(Form to be completed by referring doctors only)

This is a referral form only. To make an appointment please advise the patient to call 9654 4844 where our staff can assist.

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Oral & Maxillo-Facial Surgeons

Please select 1 of the following (required):
Kevin RuljancichAndrew A. C. HeggieJocelyn M. ShandNick J. RutherfordMark BaritNo preference

Practices

Please select 1 of the following (required):
Level 12, 63 Exhibition Street Melbourne, VIC 3000159 Tucker Road Bentleigh, VIC 3204159 Church Street, Brighton Vic 3186 / 21 Black Street, Brighton, VIC 318618 Scholar Drive, University Hill, Bundoora, VIC 3083237 Burwood Highway Burwood East, VIC 3151Suite 3003, Level 3, Westfield Tower Westfield Doncaster Shopping Centre, VIC 310812 Linacre Road, Hampton, VIC 3188428 Riversdale Road, Hawthorn East, VIC 3123Suite 1B, Level 2, 12 Hall Street, Moonee Ponds VIC 3039Private Consulting Rooms, 343-357 Blackburn Road, Mount Waverley VIC 314917 Wantirna Road, Ringwood, VIC 3134

Telephone 9654 4844 for all practices

Patients Name (required):

Patients DOB (required):

Patients Address (required):

Patients Telephone (required):

Patients Mobile (required):

Reason for Consultation (required):
Wisdom TeethImplantJaw (Orthognathic surgery)PathologyOther

Referral Notes (required):

Post Implant Surgery

The implant will be restored by myself (required): YesNo

The implant will be restored by a different practitioner (required): YesNo
If yes, please enter the different practitioner's name:

Radiographs

Type of Radiograph (required):
OPGPALateral CephC.T. ScanOther

Status of Radiographs (required):
Patient bringing to consultationReferring doctor to send in mailReferring doctor to attach radiograph below or to e-mail to mofs@mofs.com.au

Upload Radiographs here:
File size limit 5mb
File types accepted gif, png, jpg, jpeg, pdf

Referring Doctor's Name: (required)

Referring Doctor's Email: (required)

Referring Doctor's Provider Number: (required)

Referring Doctor's Address: (required)

Referring Doctor's Phone Number:

For directions, please refer to the maps on our website: MOFS Locations
Reminder: This is a referral form only. To make an appointment please advise the patient to call 9654 4844 where our staff can assist.

Please check the box below to prove you are a human, then click the 'Send' button All Emails are encrypted and sent securely.