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.

Clinician Name

Professional Registration Number (i.e. GDC)

Practice Name

Practice Address

Practice Email

Practice Contact Number

Profession

Your Contact (email or number)

Patient Details

Patient Title & Full Name

Patient Address

Patient DoB

Patient Email

Patient Contact Number

* Reason For Referral

Periodontal Disease Assessment & Management Crown Lengthening (Aesthetic or Restorative) Gum Recession Management Periodontal Opinion & Treatment Planning

Please provide more information about your referral:

What is your Provisional Diagnosis?

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

Patients will be primarily seen at:
The Dental Wellness Centre
101 Aylestone Road, Leicester, LE2 7LN

If you would like the patient to be seen elsewhere, please include this in your referral.
Thank you kindly for your referral!