Please note Dr Chesterman only currently accepts referrals for endodontics at Churchview Dental Care, Crossgates, Leeds. ← BackThank you for your response. ✨ Thank you for your referral. Referring Dentist Details 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 Primary root canal treatment Retreatment root canal treatment Apical surgery Resorption Other (Please specify below) Tooth requiring treatment:(required) Please provide a summary of the reason for referral:(required) Upload a recent radiograph/s(required) 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 root canal treatment is unsuccessful or not possible: (required) No, please refer the patient back to us Yes, please offer dental implant options as appropriate Please state which practice you are referring to(required) Church View Dental Care, Crossgates, Leeds, LS15 8BB. Honesty at the Oaks, 192 Swan Avenue, Eldwick, Bingley, BD16 3PA. Please confirm this referral is for Churchview dental care, Crossgates, Leeds (required) (required) Please confirm you have informed the patient of the referral(required) SendSubmitting form Δ Like Loading...
Dr James Chesterman 