+61 3 5213 3711
reception@geelongoralmed.com.au

19 Gheringhap Street, Geelong CBD

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Please answer these questions truthfully, or discuss them with your clinician. Information about your medical history is only for clinician use.

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Reason for Referral (Required) *Persistent or unexplained oral lesions , including ulcers, white or red patches, or mucosal changes that do not resolve with routine careSuspected or confirmed oral potentially malignant disorders, including leukoplakia, erythroplakia, dysplasia, or recurrent lesions requiring surveillanceChronic oral mucosal disease particularly immune-mediated or inflammatory conditions (e.g. lichen planus, pemphigoid, pemphigus, lupus-associated oral disease)Orofacial pain of unclear origin, including burning mouth syndrome, neuropathic pain, atypical facial pain, or persistent oral discomfort without obvious dental causeMedically complex patients with oral manifestations related to systemic disease, immunosuppression, cancer therapy, or long-term medication useOral adverse drug reactions or medication-related mucosal changesUnexplained oral dryness, burning, or sensory disturbance requiring specialist assessmentDiagnostic uncertainty , including cases requiring biopsy planning, clinicopathological correlation, or specialist opinionDental sleep medicine assessment, including evaluation for oral appliance therapy in patients with obstructive sleep apnoea or CPAP intolerance, and long-term dental/TMJ monitoringTemporomandibular disordersSecond opinions for complex, multifactorial, or diagnostically challenging oral presentationsOther

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Osteoporosis (Required) *YesNo

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Providing specialist care for orofacial pain, oral mucosal diseases, and dental sleep medicine in a compassionate, patient-centered environment.

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19 Gheringhap Street, Geelong CBD
+61 3 5213 3711
reception@geelongoralmed.com.au

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