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Referrals

Please fill in your details below and click the "Send Referral" button. If you would like to view our referral charter then please click here.

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Patient details

Treatment requested (please tick all that apply)
Endontic treatment
Post removal
Re-treatment
Broken instrument
Opinion only
Surgical endontics
Emergency extirpation
Other

I would like the endontic access sealed with:
Glass Ionomer
Bonded Amalgam
No preference
Temp dressing only

Referring practice details