Patient Referral Form
Brigstock Dental Practice
97 Brigstock Road
Thornton Heath,
CR7 7JL
T:0208 689 6171
E: [email protected]
SPECIALIST ENDODONTICS
Dr Kreena Patel BDS (Hons) MJDF RCS (Eng) MClinDent MEndo RCS(Edin)
Patient Details
Title:
Name:
Surname:
DOB:
Tel (H)
(M)
Address:
Reason for referral
Primary RCT
Re-treatment/Apicectomy
87654321
12345678
87654321
12345678
Pulp exposure
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Comments: _________________________________
Pain on biting
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History:
____________________________________________ Trauma ☐
____________________________________________ Previously root treated ☐ When? __________________
____________________________________________
____________________________________________
____________________________________________
Please tick all that apply:
Radiolucency ☐
Vague symptoms
Suspect crack
Previously attempted
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Call me for special instructions
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Referring Practitioner
Dentist Name:
Practice Name:
Practice Address:
Tel:
We will contact patients directly to make an appointment. Many thanks for your referral.
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