Referral Services

Hardeep Sahota

BDS (Hons), MJDF RCS (Eng), MClinDent Perio (Dist), CCST Perio/Implants,
M Perio RCSEd

Learn more about Hardeep

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Company

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Which referral service do you require?*

Your clinician is Christo Frick - GDC No. 78367

Your clinician is Mr. Hardeep Sahota - GDC No. 258662

Referring Dentist

Name of dentist*

Title Name Last

Tel:

Dental Practice*

Practice Address*

Street Address Address Line 2 City/Town County Post Code Country

Patient Details

Patient

Title First Last

Date of Birth

Address*

Street Address Address Line 2 City/Town County Post Code Country

Home Tel:

Mobile Tel:

Details of Referral

Reason for referral

Reason for referral - notes

Do you wish us to carry out any other necessary treatment in conjunction with our treatment (i.e. extractions, restorations)?

Yes

Oral hygiene status

Medical history

In particular, history of Bisophosphonates

Smoking*

File upload(s)

Drop files here or

Max. file size: 128 MB.

Documents uploaded

Please provide all relevant radiographs

Brief treatment history

Other comments

Consent*

Yes

I confirm that I have understood the referral criteria, and my patient understands the need for the referral and consents to be referred.

Date

Signature