Oral Surgery Referrals - My New Smile

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6 Draybank Road Broadheath Altrincham WA14 5ZL

0161 348 7830

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Home
Treatments & Solutions
Common Problems & Solutions
Meet The Team
Fees
Referrals
New Patients
Contact Us

0161 348 7830

Emergency Dental Care

Home
Treatments & Solutions
Common Problems & Solutions
Meet The Team
Fees
Referrals
New Patients
Contact Us

Menu

Home
Treatments & Solutions
Common Problems & Solutions
Meet The Team
Fees
Referrals
New Patients
Contact Us

Oral Surgery Referrals

Patient Title:

Name:

Patient Address:

Date of Birth:

Referring Dentist Name:

Practice Address:

Please provide a brief description about the affected teeth:

Medical History

Allergies Smoking Alcohol

Medication

Warfarin Aspirin Novel Anticoagulants Rivaroxaban clopidogrel Steroids Immunosuppressants Bisphosphonates Cardiac valve replacement Chemotherapy Radiotherapy Other

Other Info:

Please confirm a clear radiograph is attached (essential) Further Details (if required)

Please provide 6 point periodontal probing depths around the tooth requiring treatment

Further Details (if required)

ADDRESS

6 Draybank Road Broadheath Altrincham WA14 5ZL

OPENING TIMES

Tuesday

9:00 AM – 9:00 PM

Saturday

9:00 AM – 13:00 PM

CONTACT US

01613487830
info@mynewsmilealtrincham.co.uK

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