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Home
First Visit
Treatment
Gums & Implants
Teeth & Dentures
Referring Practitioners
Periodontist RP Form
Prosthodontist RP Form
Our Practice
Community
Contact
Prosthodontist Referring Practitioners Form
Dr Andrew Mackie – Prosthodontist Specialist
Please fill out all fields below and submit the form, or alternatively
download the PDF form
.
Referring Dentist
Name*
Practice
Address
Phone*
Fax
Email*
Patient Details
Name*
Date of Birth*
Address
Home Phone
Work Phone
Mobile Phone*
Email*
Medical History
Dental History / Oral Hygiene Methods
Smoker / Non-smoker / History
Account Number
Date of Accident
Requires antibiotic prophylaxis
Requires sedation
Non-ambulatory
Partially dentate
Abrason/Erosion
Edentulous
Bruxist
Loss of vertical dimension
Referral
Periodontal disease (differential diagnosis)
Complete dentures
Immediate dentures
Implant overdentures
Implant fixed bridge
Tooth supported crown & bridge
Bite Splint
Partial denture - maxilla / mandible
Dental Implants (sites)
Other
Notes (teeth)
Radiographs enclosed
PAs
OPG
Bite wings
Please return radiographs
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