Referrals

Dr Arthur Drouganis BDS (Adel), MDS (Adel)

Periodontal assessment & Treatment

Gingival Recession

Tooth

Crown Lengthening

Tooth

Exposure of impacted Canine

Tooth

Crown Lengthening

Maxilla

Mandible

Isolated Perio Procedure

(please specify; crown lengthening, guided tissue/bone regeneration, mucogingival recession, implantology)

Implant Assessment & Treatment

Implant Placement Only

Implant Placement & Restoration

Please specify details of the problem (specify below)

Title

Patients Surname *

First Name *

Email Address *

Date of Birth

Phone (H)

Phone (W)

Phone (M)*

Address

Suburb

Postcode

Referring Practitioner *

Radiographs Enclosed?

Yes

No

Practitioner Address

Suburb

Postcode

Email

Phone (W)

Fax

South Australia
Payneham
Berri

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Referring Practioners