Endodontic Referrals

We welcome referrals for Endodontic treatment, completed by Dr Omar Mahmood (PG Dip Endo)

Upon referral receipt we aim to contact the patient within 24hrs to arrange an appointment.

When attending, your patient will receive a consultation and fully itemised treatment plan. We aim to only complete the treatment referring dentist has requested.

Our consultation fee is £49, however this will be waived if the patient proceeds with treatment.

Upon completion the patient will be directed back to the referrer and a post treatment letter sent to the referrer.

If you wish to discuss anything further regarding our referral system please do contact us on enquiries@martondental.co.uk

Patient Details

Patient's First Name *

Patient's Last Name *

Patient's Date of Birth *

Patient's Sex *

Patient's Email:

Patient's Mobile *

Patient's Home Phone

Patient's Work Phone

Patient's Address *

Tooth / Teeth *

Priority *
UrgentNon Urgent

Radiograph *
To be sent by postTo be uploaded hereTo be emailed to marton.dentalpractice@nhs.net

Radiograph 1 Upload

Radiograph 2 Upload

Radiograph 3 Upload

Reason for Referral *

Medical History *

Referral Dentist Details

Dentist's First Name *

Dentist's Last Name *

Practice name and address

Preferred Contact Number *

Preferred Email *

Additional Comments

I have read and agree to the Marton Dental Practice'sprivacy policy. * Required

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