Endodontics referral

Dr Sarfaraaz Zahid BDS, MFDS RCS(Ed), MSc (Endo)
Specialty Registrar in Endodontics

Email – endodontics@dentalhouse.uk

Tel – 01733 245 055

114-116 Main Street
Yaxley
Peterborough
PE7 3LP

Patient Details

Patient name *

Date of birth *

Patient Address *

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Referring Dentist Details

Dentist Name *

Dentist Address *

Dentist Telephone *

Dentist Email *

Is this referral urgent? *

Reason for Referral

1. Opinion only

2. Simple treatment

3. Re-treatment

4. Abutment for bridge/new crown

5. Difficult tooth morphology (curved canals)

6. Difficult access

Other reason for referral

Has the patient been informed on costs? *

Medical History attached? *

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Pre-operative radiograph attached? *

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