Angel Smile
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reception@angelsmile.co.uk
02078373938
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Dentist Referrals
Patients referred will be contacted directly and full post-op report sent to referrer upon completion
Patient's details
Patient's name
(Required)
First
Last
Date of Birth
(Required)
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Address
(Required)
Street Address
City
Post code
Telephone
(Required)
E mail
(Required)
Patient referred for
(Required)
Implants , Sinus lifting, Computer-guided surgery by Implantologist: Dr Amin Amenien
Orthodontic treatments including Invisalign, lingual braces and Myobrace by specialist orthodontist: Dr Fariba Banaie
CEREC Same-day Crown
Root canal treatment under Microscope by Endodontist Dr Denis Aydan
Smile Design and Smile Makeover, by cosmetic or restorative dentists
Wisdom tooth & Complex extractions by specialist oral surgeon Dr Arash Shahrak
Full mouth rehab, worn oclusion and comprehensive restorations by prosthodontists
Tooth wear, reconstruction of collapsed bite, and chewing organ by prosthodontists
Advanced gum treatments, Guided biofilm therapy, by hygieneist
LASER-assisted gum treatment by dentists
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Specify tooth/teeth/areas
(Required)
Medical notes
(Required)
Upload optional radiographs, reports,
Drop files here or
Select files
Max. file size: 64 MB.
Referring Dentist / Physician Details
Referring practitioner's name
(Required)
Practice/Practitioner Telephone
(Required)
Practice/Practitioner Email
(Required)
Consent
(Required)
The patient agrees to share their personal information with Angel Smile Dental Care and to be contacted.
