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Advanced Dental and Implant Care, Leeds
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Refer a patient for dental treatment
Patient's full name
Address
Email
Date of birth
Contact tel no.
Tooth / teeth
Reason for referral (endodontics, periodontics, implants etc)
Priority
Non-urgent
Urgent
Medical history
Referring dentist name
Tel no.
Dentist GDC no.
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Upload X-ray 3
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Practice name & address
Dentist/practice email
Today's date
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Thank you for your referral. Your patient will be assessed and returned to you after their consultation or course of treatment.
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