Submit Online Referral for Perth Private Facial Trauma Service

Referral

Submit your referral by completing the form below.

Referring Doctor/Dentist/Clinic

Name
Provider Number
Address
Telephone
Fax
Email

Patient Details

Patient's Title
Patient's Name
Patient's D.O.B
Patient's Sex
Patient's Height (cm)
Patient's Weight (kg)
Patient's Address
Patient's Telephone
Patient's Email

Worker's Compensation

Worker's Compensation Case
Patient's Employer Name
Employer Contact Name
Employer Contact Number
Employer Contact Email

Imaging/Test Results

Images Available

CT
Plain Films
Name of Radiology Clinic
Patient ID Number

The patient should bring other relevant information and test reports to their initial consultation.

These can be emailed in advance to reception@fixjaw.com.au.

Injury Description

Diagnosis & Mechanism of Injury
Is the patient’s airway compromised or at risk of compromise?
Is the C-spine clear?
Is the patient at risk of or experiencing breathing difficulty, i.e. aspiration?
Is the patient’s cardiovascular system stable?
Has the patient got a head injury/did they lose consciousness? (provide details below)
Does the patient have an eye injury?
Are there other injuries?
Relevant Medical History