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Periodontics Referral Form

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    Patient Details

  • Referring Dentist Details

  • GP Details

  • Pre-Referral Checklist (Tick as appropriate)

    Prior to referral for periodontal treatment, where indicated, please tick which of the below has already been completed.

  • BPE

  • Provisional Periodontal Diagnosis

  • If other diagnosis please complete ‘Risk Factors’ and ‘Reason for Referral’ sections.

    Risk Factors

  • Reason for Referral (Tick as appropriate)

  • Conditions of Referral

  • *By clicking 'Submit' you are consenting to us replying, and storing your details. (see our privacy policy).
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    Patient Reviews

    I received amazing care. I am a nervous patient and I was treated with fantastic care. Thank you for being so caring and professional, you have helped me overcome my fear of the dentist.

    P Williams, October 2022
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    The Dental Spa have always offered me fantastic dental treatment and advice. I always recommend this practice to my friends and family!

    Anon, 2018
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    Thank you so much for helping me achieve the smile I've always wanted. I can now smile with confidence!

    Anon, 2018
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    Thank you for giving me fantastic straight teeth. I cannot tell you how much my confidence has grown. I wish you all the best success.

    Anon, 2018
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