Patient Referrals

reception@swcpc.com.au
Suite 2.12, 90 Podium Way, Oran Park New South Wales 2570, Australia

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Dr Michelle Donegan BDSc (Hons)

Dental Surgeon, Sleep Dentist

Tel: (02) 9419 5051
Fax: (02) 8080 0170

Patient Referral

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Patient Name *

Date of Birth

Date Today

Phone

Dear Dr Donegan,

I refer my patient for consultation/management of:

Snoring and Obstructive Sleep Apnoea (OSA) with a Mandibular Advancement Splint (MAS)
MAS therapy for Mild or Moderate OSA
TMD
Bruxism / Sleep Bruxism
Primary Snoring
CPAP non-compliant
CPAP/combined therapy or alternative
Broken Device/ existing splint unsatisfactory

Notes

I Phone Address

Yours Sincerely,

Signature

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Referring Doctor

Phone

Provider No

Address

Address Line 1

City

State / Province / Region

Postal Code

Locations

Inner West 431 Glebe Point Rd, Glebe NSW 2037
Eastern suburbs 1 Magney Street, Woollahra NSW 2025
North Shore 17 Gerard Street, Cremorne NSW 2090