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Patient's Name
Date of Birth


Reason for referral:
Please include tooth number and location
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Upload radiographs and clinical photos. Alternatively you can sned to
Radiograph / Radiology
Anaesthetic Choice
Nitrous oxide and intravenous sedation only available at Liverpool and Camden practices.


A copy of this referral will automatically be sent to Dr Oteng-Boateng, Toothsavers and the patient (if their email address has been entered). If you would like another copy sent elsewhere please enter the email address above.