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East of England EndodonticsEast of England Endodontics

Secure Patient Referral Form for Dentists

If you are a patient use this contact form
Please choose which practice you're referring to*

Patient Details

(Mr/Mrs etc)
Patient's Address*
Patient's Date of Birth*
Patient's Gender

Referring Dentist's Details

(Mr/Mrs etc)
Dentist's Address*

Referral Details

Is this referral for advice only or advice & treatment?*
Treatment Required*
Dental phobia
Claustrophobia
Sedation required
Restoration
To prevent post-obturation micro-leakage, it will not be possible to restore the access cavity with other materials. Should you have other preferences or needs, please kindly discuss this with us when doing the referral.

X-Rays

Please ensure that any existing X-rays are submitted / uploaded with all referrals
Additional referral information
Please include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF
Drop files here or
Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 512 MB.
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