Patient Referral Form.

Use the form below to make a endodontic referral, or download the form and email to info@renewdental.co.uk

Download Form
Dr Indy Johal

    Patient's Details

    Referring Dentist Details

    Smoking Status

    SmokerPrevious SmokerNever smoked

    Reasons for Referral

    Diagnosis / 2nd opinionVital pulp therapyPrimary root canal treatmentRe-root treatmentOther

    PABitewingCBCTOPGNone

    Patient is aware of £50 consultation fee (included if RCT provided)

    YesNo

    Patient understands and consents for referral

    YesNo