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York Dental Practice

1 Pioneer Business Park, Amy Johnson Way

Endodontic Referrals

Implant & Oral Surgery Referrals

Facial Aesthetic Referrals

Book a Consultation

1 Pioneer Business Park, Amy Johnson Way

Endodontic Referrals

Implant & Oral Surgery Referrals

Facial Aesthetic Referrals

Book a Consultation

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- Our Team
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Home
Why Us
- Our Team
- About Us
Treatments
Smile Gallery
Membership Plan
Fees
Contact

Endodontic Referrals (For Dentists) Root Canal Treatment

Endondontic Referral Form For Root Canal Treatment in York (Clifton Moor)

Undertaken by Dr Mahesh Vasireddy

York Dental Practice.1 Pioneer Business Park, Amy Johnson Way, York YO30 4TN

Tel: 01904 891160

PATIENT DETAILS

Date of referral*

Dentist Name*

GDC Number*

Telephone Number*

Practice Name*

Practice Email*

Practice Address*

Patient Name*

Last*

Date of Birth*

Email*

Patient Telephone Number*

Patient Mobile Number*

Patient Address*

Post Code*

Which tooth/teeth require endodontic assessment/treatment?*

Reason for Endodontic referral*

Tooth notation*

Please describe the history of the patient’s complaint, symptoms and clinical signs:

Treatment required*

Consultation only Primary root canal Re-treatment Removal of fractured instrument Apical surgery

Please enclose relevant radiographs, if available. These will be returned to you at the end of the treatment (You can upload up to 10 files each being max. 10MB)

Will the following be needed after treatment?*

Temporary restoration Permanent core Prepare post-space Permanent restoration None

Specific patient problem(s)*

Relevant medical history*

Additional Comments*

Privacy Policy*

I consent to my personal data being collected as per our Privacy Policy*

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Please use the online form below. Fields in (*) are required.

I am a New PatientI am an Existing Patient

Existing patients please note: To CANCEL OR RESCHEDULE your appointment you need to please call us on 01904 891160.

I consent to my personal data being collected as per our Privacy Policy

York Dentist

01904 891160
1 Pioneer Business Park, Amy Johnson Way, York YO30 4TN

Opening Times

Monday: 8:30am – 5.30pm
Tuesday: 8:30am – 5.30pm
Wednesday: 8:30am – 5.30pm
Thursday: 8:30am – 5.30pm
Friday: 8:30am – 5.30pm

Out of opening hours please contact 111

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