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Wisdom Teeth
Dental Implants
Anaesthesia
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Galileos X-Ray Machine
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FAQS
Contact Us
Contact Us
09 529 5910
Team
Procedure Information
Dentists & GPs
Satellite Offices
FAQS
Contact Us
Dentists & GPs
Galileos Scan Referral Only
Oral Surgery Associates
/
Dentists & GPs
/
Galileos Scan Referral Only
Please fill out this form, and we'll be in touch as soon as possible.
Referral
Form
Dentist/GP Name
Dentist/GP Address
Dentist City
Dentist Postal / Zip Code
Phone
Date
Patient Name
Patient Street Address
Patient City
Patient Postal / Zip Code
Date of Birth
Home Phone
Business Phone
Mobile Phone
Email Address
Area of Interest/Reason for Referral
Would you please examine this patient and...
Assess and treat as needed
Treat as indicated
X-rays attached
Please return X-rays
Please phone me
Significant medical history
This is regarding...
CBCT (Wrap and Go)
Dicom Export
Dicom 3rd Party
Orthodontics
Do you want the surgeon to call you to discuss the scan?
Give scan to patient
Please upload any X-Rays
Choose a file