← 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 Other (please specify below) Please provide a summary of the reason for referral:(required) Upload a recent radiograph/s 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 Where appropriate please confirm that patient is aware that advanced treatment may not be appropriate due to overall dental heath status and clinical scenario (required) Please confirm this referral is for dental implants and/or periodontal treatment(required) Please confirm you have informed the patient of the referral and estimate of consultation fee £150-220. We will also confirm this with the patient prior to booking. (required) SendSubmitting form Δ Like Loading...
Dr James Chesterman 