ADELAIDE | REYNELLA | BERRI

Australia's Premier Periodontics Specialist

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REFERRALS

Referring Practioners

National Periodontics provides specialist periodontal services throughout Australia. We have provided a simple referral form which allows your patient to be seen at one of our convenient locations.

Referral Details *

Dr Arthur Drouganis BDS (Adel), MDS (Adel)
Dr Ranu Acharya BDS, Grad Cert (Clinical Dentistry) (Melb), ClinDent (Perio) (Adel) Periodontal Registrar

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

8 7 6 5 4 3 2 1

8 7 6 5 4 3 2 1

8 7 6 5 4 3 2 1

8 7 6 5 4 3 2 1

Implant Placement Only

Implant Placement & Restoration

Please specify details of the problem (specify below)

Patient Details

Title

Patients Surname *

First Name *

Email Address *

Date of Birth

Phone (H)

Phone (W)

Phone (M)*

Address

Suburb

Postcode

Referrers Details

Referring Practitioner *

Radiographs Enclosed?

Yes

No

Practitioner Address

Suburb

Postcode

Email

Phone (W)

Fax

Please Choose a Clinic *

South Australia
Payneham
Reynella
Berri

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FIND US

National Periodontics Head Office:
250 Payneham Rd
Payneham, SA 5070

FIND OTHER LOCATIONS

Phone: +610 883633700
Fax: +61 08 8363 3744
E-mail: payneham@natper.com.au

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