Adelaide
Tooth Removals
& Dental Implants
Dr Andrew J Chan
BDS MD FRACDS
Dr Lawrence M Ebel
DMD FICOI
Patient details
Name
Date of birth
Phone
SMS notification sent if mobile
Email
Patient will receive email summary of referral
Extractions
Tooth numbers
Please also select teeth on diagram to be considered for extraction
18
17
16
15
14
13
12
11
21
22
23
24
25
26
27
28
48
47
46
45
44
43
42
41
31
32
33
34
35
36
37
38
Dental implants
Tooth numbers
Preferred system
If no preference is selected we will likely use Straumann implants.
Other services
Notes, relevant medical history
Referred by
Dr name
Practice
Suburb
Email *
Referred to preference
Patient preference, surgeon availability & surgeon's area of interest will also be considered.
Attach X-rays / images
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OPG, PA, CBCT — JPG, PNG, PDF · Max 20MB per file

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Referral emailed to referrals@adelaideoralhealthco.com.au. You'll also receive a copy emailed to you.
For urgent cases call (08) 8164 5546

Information submitted via this form is collected for the purpose of facilitating oral health care and is handled in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles. Adelaide Oral Health Co. Pty Ltd takes reasonable steps to protect patient information from misuse, interference, loss, and unauthorised access. This form is transmitted securely via TLS encryption.