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Referring Practitioner

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Patient Details

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Parents/Guardian details

(For children under 16 years of age)

Medical History

Oral Health

Teeth to treat

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Level of Urgency

Referral Details

Referral Treatment*
I would like to be present during the consultation/treatment
I would like you to contact me to discuss the case
I would like you to treat as you see necessary and let me know of your plan for this case
I would like to restore this case (implant placement only)
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    Kissdental

    Manchester

    City Centre
    13 Stanley Street
    Manchester
    M8 8SH
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