PATIENT REFERRAL

Dr Alex Fibishenko
BDSc FICOI

PRACTICE EXCLUSIVE TO IMPLANT
& RECONSTRUCTIVE DENTISTRY

265 Burwood Hwy, Burwood East, VIC 3151
T. +61 (03) 9802 2399 F. +61 (03) 9887 9430


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Patient Information
TitleSurnameOther Names
D.O.B.AgeTel
Home AddressP/C
Reason for Refferal
Second Opinion Treatment as RequiredSurgical Implant Placement Only
Sinus Graft Onlay Bone GraftingManagement of Complication
Extraction & Socket Preservation Extraction & Immediate ImplantsImmediate Function
All-On-4 NobelGuide Surgical PlanningSoft Tissue Surgery
Further Details
Attachments
Who will perform the restorative course of treatment?
  Dr Fibishenko  Myself  Different Practitioner
  I will be attending for the procedures
  I am registered with Implant Team Academy
  I’d like to perform certain components of the procedure at your clinic
Referring Practitioner
NameTel
AddressP/C
E-mailDate