Dentists please complete the form below if you wish to refer patients to dentalessence for oral Surgery.
We will reply to your request as soon as we can.
* indicates required field
(Please indicate in which area(s) treatment is required, for fees refer to website)
Surgical extractionWisdom tooth extractionSoft tissue biopsy - FrenectomySoft tissue - Perio plastic surgeryApicectomy
Radiographs Included
YesNo
Attach Radiograph (file types accepted gif/png/jpeg)
File name to include referring dentist name, patient initials and patient DOB.
OPGBite wingsPeri-ApicalCBCT
Will the patient benefit from sedation
Is your patient a regular attender to the hygienist?
Frequency of hygiene attendance
Never1 per year2 per year3 per year4 per year
This will act as the practitioner’s electronic signature: I hereby authorize dentalessence to carry out an oral surgery consultation as outlined above.
We also provide the following services on a referral basis. Please click on the links below for the individual referral forms.
