Dentists can refer their patients to a specialist at MDS by completing this form

Manchester Dental Specialists Patient Referral Form

To refer a patient please complete the online form below and when completed press SUBMIT at the bottom of the page.

Referral Requirements
(tick all that apply)

Endodontics

Temporomandibular Disorders

Implantology

Periodontics

Prosthodontics

Surgical Dentistry

If known, please tick which specialist you wish your patient to be seen by

Amin Aminian BDS MSc MFDS RCPS(Glas) MRD RCS(Edin)

Martin Ashley BDS(Hons) FDSRCS(Eng) FDS(Rest Dent) RCS MPhil

Sanjeev Bhanderi BDS MSc

Robin Gray BDS MDS PhD MFGDP(UK)

Neil Wilson BDS MSc MFGDP(UK) MFDS RCPS(Glas) MRD RCS(Edin)

Referring Dentist Details

Name

Address

Postcode

Tel

Mobile

Fax

Patient Details

Name

Gender

Address

Postcode

Tel

Mobile

Fax

Date of Birth

(Please include reason for referral and specific problem areas)

Referral Information

(Please include any radiographs and models which may help in evaluating the patient. We will return them to you after use)

Relevant Medical History

Manchester Dental Specialists
62 Manchester Road, Altrincham, Cheshire, WA14 4PJ
t    0161 924 0335 f 0161 924 0330
e   info@manchesterdentalspecialists.co.uk
w   www.manchesterdentalspecialists.co.uk