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reception@swcpc.com.au
Suite 2.12, 90 Podium Way, Oran Park New South Wales 2570, Australia
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OurTeam
Dr Saurabh Gupta
Dr Haider Naqvi
Dr Shervin Amirmalek
Dr Michelle Donegan
Shondell Tilden
Services
Respiratory
Respiratory Function Testing
Sleep
Home Based Sleep Studies
Mandibular Advancement Splint (MAS) Consultation
Patients Resources
Practitioner Resources
Contact Us
Menu
Home
OurTeam
Dr Saurabh Gupta
Dr Haider Naqvi
Dr Shervin Amirmalek
Dr Michelle Donegan
Shondell Tilden
Services
Respiratory
Respiratory Function Testing
Sleep
Home Based Sleep Studies
Mandibular Advancement Splint (MAS) Consultation
Patients Resources
Practitioner Resources
Contact Us
(02) 4607 5010
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
Yours Sincerely,
Signature
(Type in name for signature)
Referring Doctor
Phone
refer Doctor Yours
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
CC Letter to BIP
Refer back for sleep study, MAS in Situ
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