Referrals – Advancesmile

15 Allerton Rd, Liverpool L18 1LG, United Kingdom

Mon - Fri : 9 am - 5 pm

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Referral Form

This form is for use by dentists to refer patients to the practice. A PDF copy of your referral will be available for download immediately after submission.

Patient Name

Patient Date of birth

Patient Address

Postcode

Patient Contact Phone Number

Patient Email

I am referring for

Implants – Paul Swanson BDS MFGDP(UK) PG Cert (Sed) DipImpDent RCS (Eng) MSc (Implant) Implants – Abd Kouzali BDS, RCS(Eng) Restorative – Steven Barber BDS MFDS RCPS FDS (Rest Dent) RCPS Periodontal Team Periodontal – Ian Dunn BCHD MFGDP (UK) MSC (Perio) Periodontal – Ruth Crook BDS MSc (Perio) Dundee Periodontal – Michael Goodman BDS Msc (Perio) Sheffield Endodontic Team Endodontics – Michael Dodd BDS (hons), MFDS RCS (Edin) DDSc (Endo), MEndo RCS (Edin), PGCert HE. Endodontics – Ian Bowles, BChD, MFGDP (UK), DipRestDent RCS(Eng), MSc (Endo) Orthodontics – Andrew Garry BA, BDentSc, MFDS, M.Orth (RCS Ed), DDSc Oral Surgery – Abd Kouzali BDS, RCS(Eng) Radiography IV Sedation Inhalation Sedation

Teeth to treat

UR8 UR7 UR6 UR5 UR4 UR3 UR2 UR1 UL1 UL2 UL3 UL4 UL5 UL6 UL7 UL8 LR8 LR7 LR6 LR5 LR4 LR3 LR2 LR1 LL1 LL2 LL3 LL4 LL5 LL6 LL7 LL8

Relevant Medical History & Current Medications

Smoker?

Yes No

Case History

Please send any relevant radiographs, not just most recent

Dentist Name

GDC Number

Dentist Email

Dentist Phone

Practice Address

Advance Smile offers expert, gentle dental care to keep your smile healthy and bright.

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