Full Name
DOB
Address
City
Postcode
Phone number
Email
Please upload relevant digital x-rays
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Tooth/teeth to be treated:
History of presenting complaint:
Additional Information:
Relevant medical history:
Treatment requested (please tick all that apply)
Cosmetic Treatment Endodontic Treatment
Opinion onlyPrimary root treatmentRe-treatmentEmergency extirpationRestorability assessmentPost removalInstrument removalSurgical endodonticsOther
The endodontic access will be sealed with a permanent core of amalgam or composite. If there is a preference; please specify below.
No preferenceCompositeAmalgamGlass IonomerPost and core
Name
Referring dentist name
Contact email
Telephone number
We’re a friendly team of dentists working together to ensure that you receive the best treatment that you require.
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