Professional Referrals

Refer a patient for a Periodontal Consultation

with Dr Dhroov Thanki PgDip (Perio)

Referrer Details

The fee for a periodontal consultation is £55, which goes towards treatment.

Practice Name

Practice Address

Practice Email

Practice Number

Clinician Name

Professional Registration Number (i.e. GDC)

Profession

Contact (email or number)

Patient Details

Patient Title & Full Name

Patient Address

Patient DoB

Patient Email

Patient Contact Number

* Reason For Referral

Gum Health Clinical Opinion & Treatment Planning Aesthetic Crown Lengthening (“Gum Lift”) Restorative Crown Lengthening Gum Recession Surgery

Please provide more information about your referral, please include a provisional periodontal diagnosis

* PLEASE ATTACH RADIOGRAPHS, PHOTOGRAPHS AND BPE / 6 POINT POCKET CHARTING

I will organise to see the patient at either:
Aylestone House Dental Practice, 345-347 Aylestone Road, Leicester, LE2 8TA
or
The Dental Wellness Centre. 101 Aylestone Road, Leicester, LE2 7LN
Thank you kindly for your referral!