• 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 for Perth Private Facial Trauma Service

Submit your referral by completing the form below.

    Referrer Details

    Doctor/Dentist Name


    Provider Number




    Your 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 Phone/Mobile

    Patient's Email

    Being Referred To

    Worker's Compensation

    Worker's Compensation Case

    Patient's Employer Name

    Employer Contact Name

    Employer Contact Number

    Employer Contact Email

    Imaging/Test Results

    CT Images Available

    Plain Film Images Available

    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