Periodontal 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 seperately via email by clicking this link.

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

Patient recordsIn post? YesNoor Uploaded/EmailedTo Return? YesNo
Consent formIn post? YesNoor Uploaded/EmailedTo Return? YesNo
Study modelsIn post? YesNoor Uploaded/EmailedTo Return? YesNo
Radiographs Intra-oral:
In post? YesNoor Uploaded/EmailedTo Return? YesNo
Radiographs Panoral:In post? YesNoor Uploaded/EmailedTo Return? YesNo
Dental historyIn post? YesNoor Uploaded/EmailedTo Return? YesNo