Patient Details

      Patient Details

    • Referring Dentist

    • Nature Of Referral

    • STATUS & Treatment Required:

      • This patient attends our practice regularly
      • This patient is new to our practice
      • The problem is generalised
      • The problem is localised to:

      Please click on the tooth notation relating to the area of interest (if applicable).

        Upper Right

      • 9
      • 8
      • 7
      • 6
      • 5
      • 4
      • 3
      • 2
      • 1

        Upper Left

      • 1
      • 2
      • 3
      • 4
      • 5
      • 6
      • 7
      • 8

        Lower Right

      • 8
      • 7
      • 6
      • 5
      • 4
      • 3
      • 2
      • 1

        Lower Left

      • 1
      • 2
      • 3
      • 4
      • 5
      • 6
      • 7
      • 8

    • Medical History

    • YesNo
    • Attachments

      • Radiographs
      • Clinical photographs
      • Study models
      • CT scan
      • Other


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