Submit Online Referral for Perth Private Facial Trauma Service Submit your referral by completing the form below. Referrer Details Doctor/Dentist Name Clinic Provider Number Address Phone/mobile Fax Your email Patient Details Patient's Title DrMrMrsMsMiss Patient's Name Patient's D.O.B Patient's Sex MaleFemale Patient's Height (cm) Patient's Weight (kg) Patient's Address Patient's Phone/Mobile Patient's Email Being Referred To A/Clinical Prof Dieter GebauerProf. Raymond Williamson Worker's Compensation Worker's Compensation Case Yes - Please complete belowNo Patient's Employer Name Employer Contact Name Employer Contact Number Employer Contact Email Imaging/Test Results CT Images Available YesNo Plain Film Images Available YesNo 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? YesNo Is the C-spine clear? YesNo Is the patient at risk of or experiencing breathing difficulty, i.e. aspiration? YesNo Is the patient’s cardiovascular system stable? YesNo Has the patient got a head injury/did they lose consciousness? (provide details below) YesNo Does the patient have an eye injury? YesNo Are there other injuries? YesNo Relevant Medical History
