← BackThank you for your response. ✨ Thank you for your referral. Referring Dentist Details Please complete the referral form below. Once received we will contact the patient to offer a consultation. If the patient is booked in we will provide a written report. Consultation fees range from £150 (i.e. implants/endodontics) to £220 (i.e periodontal) depending on reason for referral and complexity of the case. Consultations will be 45-60mins. Referring Dentist Name(required) Referring Practice (required) Practice Address(required) Practice Email (required) Practice Telephone(required) Patient Details Patient Name(required) Patient date of birth(required) Patient Address(required) Phone Number(required) Mobile Number (required) Referral Details Reason for referral (required) Select one option Dental implants Peri-implantitis Implant overdentures Periodontal disease Recession Surgical crown lengthening Primary root canal treatment Retreatment root canal treatment Apical surgery Root resorption Other (Please specify below) Please provide a summary of the reason for referral:(required) Upload a recent radiograph/s (required for endodontic referral) Drag and drop or click to select a file. · Uploading… Uploaded Additional radiograph/photo 1 Drag and drop or click to select a file. · Uploading… Uploaded Additional radiograph/photo 2 Drag and drop or click to select a file. · Uploading… Uploaded Additional radiograph/photo 3 Drag and drop or click to select a file. · Uploading… Uploaded If further xrays or files are required please forward these to restorativedentist@outlook.com Are you happy for us to offer dental implant options if endodontic treatment is unsuccessful/not possible: (required) Not applicable Yes, please offer dental implant options as appropriate No, please refer the patient back to us Are you happy for us to offer indirect restoration following endodontic treatment: (required) Not applicable Yes, please offer indirect restoration options as appropriate No, please refer the patient back to us Please confirm this referral is for Churchview dental care, Crossgates, Leeds (required) Please confirm you have informed the patient of the referral and consultation fee £150-220. We will also conform this with the patient prior to booking.(required) SendSubmitting form Δ Like Loading...
Dr James Chesterman 