Endodontics Referral – New Life Teeth

Endodontics Referrals

Please complete the form below for an Endodontics referral to our Belfast clinic.

Dr Marc Harrington in Belfast. BDS Hons (QUB) MFDS 2018 (RCSEd) PGCertClinEd (QUB) BSc (UU)

Please note for Endodontic referrals in Edinburgh please contact Arvind Sharma directly www.asendodontics.com)

Please complete the form below for an Endodontics referral to our Belfast clinic*

Dr Mark Harrington Endodontics in Belfast

(Please note for Endodontic referrals in Edinburgh please contact Arvind Sharma directly www.asendodontics.com)

Patient Details

Patient's Name*

Patient's Date of Birth*

Patient's Address*

Street Address Address Line 2 City County Post Code

Patient Phone Number (Home)

Patient Phone Number (Work)

Patient's Phone Number (Mobile)

Patient's Email*

Referring Dentist

Dentist's Name*

Dentist's Phone Number

Practice Address*

Street Address Address Line 2 City County Post Code

Dentist Email*

Referral Information

Referral notes*

Treatment Requested*

Preferred post-Op Restoration*

Temporary

Composite Core

Fibre Post/Core Build Up

Attachments

Please upload an X-ray attachment, if available.

Do you have additional files to send in support of this referral?

Yes

How will you be sending attachments?*

By email

Attached to this form

Digital radiographs can also be sent to endo@newlifeteeth.co.uk

File Attachments

Drop files here or

Accepted file types: jpg, pdf, doc, docx, png, Max. file size: 64 MB.

Signature

Phone

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Endodontics Referrals

Patient Details

Referring Dentist

Referral Information

Attachments

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