prof. dr. liviu steier | dr. siavash mirfendereski

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Referrals

Referring Colleague

Referring Colleague

Name *
Address *
Tel: *

Patient's Details

Patient's Details

Date
Miss/Mrs/Ms/Mr Surname *
Forename *
Date of birth
Adress *
Postcode *
Telephone No *

Main complaint/Reason for referral

Main complaint/Reason for referral

Comment

Relevant medical history

Relevant medical history

Comment

Clinical details (please circle)

Clinical details (please circle)

Problem tooth/teeth *
Pain *
Swelling *
Vital *
Periapical lesion *
Recent restoration *
Previous RCT *
Type of root filling *
X-ray enclosed *
Edentate area needing restiration *
Bone Management *
Occlusal Rehabilitation *
Cranio-Mandibular Disorder *
Dento-Facial Lifting *