Dear Dr MacMillan,

The following referral has been made by #name# of #practice#. They can be contacted at #email# and #phone#.

Provider Number: (if supplied) #providernumber#

PATIENT DETAILS

LOCATION: #location#

Patient Name: #patientname#
DOB: #dob#
Patient Phone: #patientphone#
Issues: #issue1# #issue2#
Tooth Numbers: #toothnumbers#
Clinical Notes:
#comments#

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Online contact form by WebInjection - Medical Website Design by Doctors for Doctors
User IP: #ip# | User Browser: #browser#

Dear #name#,

Thank you for making an online referral to Dr Andrew MacMillan. This email confirms that the referral has been sent. A copy of your referral is provided below. You have provided the following information to Dr MacMillan.

YOUR DETAILS

Practice: #practice#
Email: #email#
Phone: #phone#
Provider Number: #providernumber#

PATIENT DETAILS

Patient Name: #patientname#
DOB: #dob#
Patient Phone: #patientphone#
LOCATION: #location#
Issues: #issue1# #issue2#
Tooth Numbers: #toothnumbers#
Clinical Notes:
#comments#


Dr Andrew MacMillan - Oral Maxillofacial Surgeon
Toowoomba: 07 4639 1798