TeleOralMedicine is a convenient and easy-to-use online service for all Australians who need Oral Medicine Services especially those living in remote areas or aged care facilities who do not have access to specialised Oral Medicine Services.

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Pain Referral Form

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Patient Name

Date of birth

Address

Email

Telephone Number

Referrer Details

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Date

Reason for Referral

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Clinical Findings

Facial asymmetry?Yes51No51

Restriction in opening?Yes52No52

TMJ sounds?Yes53No53

LeftRightBoth

Pain upon palpation of TMJs?Yes54No54

LeftRightBoth

Pain upon palpation of masseter muscles?Yes55No55

LeftRightBoth

Pain upon palpation of temporalis muscles?Yes56No56

LeftRightBoth

Has dental pathology been excluded?Yes57No57

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Any other relevant clinical findings?Yes58No58

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Upload all relevant extraoral images, intraoral images, videos, and radiographs that will supplement the TeleOralMedicine consultation.

Please note: A copy of this referral will be sent to you and the patient you have just referred. If you have not received a copy within 24 hours, please resubmit the referral or call our team on 1300 988 957.

Oral Referral Form

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Patient Name

Date of birth

Address

Email

Telephone Number

Referrer Details

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5

Date

Reason for Referral

Duration the complaint has been present

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Clinical Findings

Positive lymph nodes?Yes1No1

FirmFixedTender

Facial swelling?Yes2No2

SubtleObvious

Intraoral pathology?Yes3No3

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Any other relevant findings?Yes4No4

Any interventions trialled?Yes5No5

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2

3

4

5

Upload all relevant extraoral images, intraoral images, videos, and radiographs that will supplement the TeleOralMedicine consultation.

Please note: A copy of this referral will be sent to you and the patient you have just referred. If you have not received a copy within 24 hours, please resubmit the referral or call our team on 1300 988 957.