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Practitioners Referral

If you are a dentist or doctor and would like to refer a patient please fill in the on-line form below.

Practitioners Referral Request Form
Patient Details:
Title
Name
DOB
Address
Postcode
Tel
I would be grateful if you could see the above patient for:
Teeth To Be Treated – Please Annotate As Required:
Oral Surgery - Private / Independent / NHS (delete as required)
Endodontics (private only)
Implants (private only)
Hygienist (private only)
Dental Treatment Under IV Sedation For Anxious Patients
Periodontics:
Periodontal assessment and treatment
The problem is generalised generalised localised to
Perio Surgery, please specify:
Gingival Plastic SurgeryCrown LengtheningRidge Augmentation
Surgical Endondontics
Associated problems:
PainRecurrent abscessesSwellingTooth MobilityBleeding
Bad breath/taste.Other
BPE score:

Please indicate if you/your hygienist will be willing to carry out maintenance therapy once the active treatment has been completed: YES / NO
In the meantime patients will continue to see you for routine dental check ups and treatment.
Relevant Medical History:

Referring Dentist
Name
Address
Tel
Date:

Fax Number:

020 8445 1265

Address:

London Day Surgery Centre
Gloucester House
150 Woodside Lane
London
N12 8TPP