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Flint and Flint
Sheffield Smile Clinic
BDA Member
T: 0114 262 0334
E:
reception@flintandflint.co.uk
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Patient Details
Title:
First Name:
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Surname:
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Date of Birth:
Home Telephone:
Work Telephone:
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Mobile:
Email:
*
Patient Address:
Medication:
Date of Referral:
Medical History:
Referring Dentist Details
Dentist Address:
*
Referring Dentist:
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Practice E-mail:
*
For the evaluation / treatment of (Please click teeth to highlight)
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Periodontal treatment:
Implant Treatment:
Individual tooth / teeth
Do you wish to carry out:
General periodontal disease
Surgical aspect only
Periodontal plastic surgery(crown lengthening, treatment of recession details etc).
Surgical & restorative aspects
Orthodontic Treatment:
Endodontic treatment only:
Orthodontic Assesment
Coronal Restoration if required Yes
Coronal Restoration if required No
Please enclose radiographs taken in the past twelve months
Radiographs enclosed
Date Taken:
History of Presenting Problem & Other Relevent Information:
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(this is an anti-spam measure)
