Orthodontics Referral Form

    REFERRING DENTIST

    PATIENT DETAILS

    I wish to refer the above patient for a private consultation and treatment regarding:

    BPE

    Please tick as appropriate

    Referral details

    Urgent referrals should be clearly marked and given priority

    We can assist with

    • Treatment of Gingivitis

    • Treatment of Periodontal disease

    • Gum disease treatment around implants - Peri-implantitis

    • Correction of uneven gum line (crown lengthening)

    • Cosmetic gum graft to correct gum shrinkage

    • Treatment of halitosis

    Access to patient results

    Results of investigations are included within patient letters.

    Documents

    Small documents can be uploaded here. If you are intending to send us documents over 2MB in size please send them separately via email by clicking this link.

    Document 1:
    Document 2:
    Document 3:
    Document 4:

    Patient records

    In post?YesNoor Uploaded/Emailed

    To Return?YesNo

    Consent form

    In post?YesNoor Uploaded/Emailed

    To Return?YesNo

    Study models

    In post?YesNoor Uploaded/Emailed

    To Return?YesNo

    Radiographs Intra-oral:

    In post?YesNoor Uploaded/Emailed

    To Return?YesNo

    Radiographs Panoral:

    In post?YesNoor Uploaded/Emailed

    To Return?YesNo

    Dental history

    In post?YesNoor Uploaded/Emailed

    To Return?YesNo

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