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Refer a Patient

Referring your patient to Exact Orthodontics is easy! Just fill out the form below or send your patients details to us through MediRef! At Exact Orthodontics your patient is in good hands.

Patient referral form

Patient's Full Name

Patient's Contact Number

Patient's Gender

Male

Female

Patient's Email Address

Birthday

Referred by

Practice Name

Appointment to be made via

Patient needs contacting to make an appointment

Patient will call to make an appointment

Referral Reason

Crowding

Crossbite

Deep bite

Overjet

Perio-ortho concerns

Open bite

Spacing

Pre-restorative

Reverse overjet

Missing teeth

Tooth wear

Trauma management

Other

Additional notes

Preferred Practitioner

Dr Lisa Sakzewski

Dr Laura Barbagallo

Next available appointment

OPG supplied?

Yes

No

Please attach relevant records

Choose File

Upload supported file (Max 15MB)

Thanks for submitting!

If you are having difficulties referring a patient please get in touch with our team on (07) 3878 4990.

About
Treatments
Orthodontics
Patient Information
Refer a Patient
Contact Us
More

Use tab to navigate through the menu items.

© 2021 Exact Orthodontics - Proudly Part of Maven Dental

All Rights Reserved

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