Call us Today :
0121 308 8977
CONTACT
Home
Treatments
Dental Implants
Child’s Teeth
Oral Surgery & Tooth Extraction in Sutton Coldfield
Dental Veneers
White Fillings
Composite Veneers / Bonding
Teeth Whitening
Smile Makeovers
Family Dentistry
Help
Dental Phobia & Fear Of The Dentist
Causes Of Bad Breath
Oral Hygiene
Preventitive Dentistry
Our Technology
Meet The Team
Fees
Smile Club
FAQs
Referrals
Endodontics With Dr. Rajiv
Referral Form
Referring to our Endodontics Specialist, Dr. Rajiv
For the full information pack, please click
here
.
Referring Dentist
Practice Name
Practice Email
Practice Contact Number
Patient Title
Mr.
Mrs.
Ms.
Miss
Other
Patient Name
Patient Address
Patient Contact Number
Patient Email
Reason for Referral
Complex Anterior/Posterior RCTs
Complex Re-Root Treatments
Endodontic Post placement/instrument retrieval
Curved/ Sclerosed canals
Endodontic Microsurgery/ Perforation repair
Is this referral urgent?
Yes
No
Brief History / Comments About This Referral
Investigations Already Done
Attach Radiographs
Attach Photos
Has the patient been informed of costs of consultation/ treatment?
Yes
No
Has the patient been informed on the location of Smile Solutions?
Yes
No
Send
