Refer Your Patient

Dr Sneha Gokhale accepts referrals for dental implants and periodontics for patients in Burton and the surrounding area.

Dr Gokhale is a specialist periodontist with a wide range of experience - please read more about Sneha on our team page here.

Dr. Sanket is accepting referrals for complex endodontic cases.

Please complete all required fields marked*

Referring Dentist Contact Details

Referring Dentist's Name*

Dentist's Email*

Dentist Practice Address

Practice Postcode

Practice Telephone number *

Dentist Mobile telephone number

Patient Contact Details

Patient Name*

Patient Address

Patient Date of Birth*

Patient Postcode

Patient Home Telephone number

Patient Work Telephone number

Patient Mobile Telephone number

Comments

Reason for Referral - Perio/Endo

Relevant Medical History

Comments

Attach radiograph file if available:
Please attach file as a jpeg, file size no greater than 3MB

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