Oral Surgery Referral

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.

    Your Practice Details (please ensure this section is fully completed)

    * indicates required field

    Patient Details

    Treatment Required

    (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

    YesNo

    Is your patient a regular attender to the hygienist?

    YesNo

    Frequency of hygiene attendance

    Never1 per year2 per year3 per year4 per year

    Referring Dentist Details

    This will act as the practitioner’s electronic signature: I hereby authorize dentalessence to carry out an oral surgery consultation as outlined above.

    Dentist Referrals

    We also provide the following services on a referral basis.
    Please click on the links below for the individual referral forms.

    CBCT Referral Form
    Hygienist Referral Form
    Implant Referral Form
    OPG Referral Form