Endodontics referral - Dental House

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

114-116 Main Street
Yaxley
Peterborough
PE7 3LP

Patient name *

Date of birth *

Patient Address *

Patient Phone

Patient Email

Patient Mobile

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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Upload Medical History 2

Upload Medical History 3

Upload Medical History 4

Pre-operative radiograph attached? *

Upload Pre-operative radiograph 1

Upload Pre-operative radiograph 2

Upload Pre-operative radiograph 3

Upload Pre-operative radiograph 4

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