• Walcott Street Surgical Centre

    41 Walcott Street, Mount Lawley
    Western Australia 6050

  • Hours of Operation

    8:00am - 5:30pm
    Monday to Friday

  • Contact Us

    08 9328 3006

Submit Online Referral

Submit your referral by completing the form below.
Please note: as of the 1st of July 2025, Professor Gebauer will not longer bill DVA for treatment for new referrals.
Patient with an existing referral will still be treated as previously agreed, however, new patients will be billed as "private patients", subject to Medicare and/or private health insurance rebates, as applicable.

    Referrer Details

    Doctor/Dentist Name

    Provider Number

    Practice Name

    Practice Address

    Practice Phone

    Practice Email

    Patient Details

    Patient's Name

    Patient's Title

    Patient's Sex

    Patient's D.O.B

    Patient's Address

    Patient's Phone/Mobile

    Patient's Email

    Being Referred To

    Treatment Required

    Referral Text


    If an urgent consultation is required please call our rooms on 9328 3006.

    Radiographs

    Radiographs Available

    Radiograph Attachment 1

    Radiograph Attachment 2

    Radiograph Attachment 3

    Implant Information

    Implant system preferred

    Surgical guide stent

    Study Model