REFERRING DENTIST
PATIENT DETAILS
I wish to refer the above patient for a private consultation and treatment regarding:
Generalised Periodontal DiseasePeriodontal Destruction Particularly Associated with
BPE
Please tick as appropriate
8765432112345678
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
Study models
Radiographs Intra-oral:
Radiographs Panoral:
Dental history
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