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Periodontics - Referring Dentists
 

The following form is reserved only for dental professionals.

Please complete the details below and then click on the submit button at the bottom.
You will be able to print out the referral details to give to your patient on the next screen.

* = required information

Patient details:

Title

Address:*

City:*

Email:

Mobile:*

Date of birth (e.g. 19/07/81)

 

Appointment:

Reason for referral/patients complaint:

Alternatively you can post the radiographs to us, we will scan them in and send them back straight away.

Consultation only:

Type of Treatment:

 

Consultation:
£135
incl Dental Report

Non-Surgical Per Quadrant:
from £200

Surgical treatment:
from £700

We respect your referral is your patient.

Rest assured referred patients will be returned back to their referring dentist (unless otherwise requested) once consultation/treatment has been completed. We will routinely send a dental report for your records.

Please contact us at any time should you have any queries or if you would like to any update on any of treatment proposed.

 

 

 

Referring dentist details:

Name:*



Practice:*

Email:

Phone:*

Please type in the code from this image.*

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