Home
About Mr Aldaadaa
Oral Surgery
Implant Dentistry
Conscious Sedation
Non-Surgical Facial Aesthetics
Transformations
Education
Publications
Fees
Referrals
Blog
Contact Me
Menu
Select a Location
SW1 Dental - SW1P 3LT
Twoth Dental - NW8 7SH
OrthoSmile - SW5 9AH
The Orthodontic Suite - SE21 8SZ
The Oxford Smile Clinic - OX11 8RN
London Smile Care - W1G 6LD
020 4542 0155
Referrals
Contact Me
About Mr Aldaadaa
Procedures
Transformations
Education
Publications
Referrals
Contact Me
Referrals
Home
/
Referrals
Select a Location
SW1 Dental - SW1P 3LT
Twoth Dental - NW8 7SH
OrthoSmile - SW5 9AH
The Orthodontic Suite - SE21 8SZ
The Oxford Smile Clinic - OX11 8RN
London Smile Care - W1G 6LD
Referrals
Contact Me
Oral Surgery Referral Form
Refer to Mr Alaa Aldaadaa (Specialist Oral Surgeon)
Phone
Referring clinician:
Referring clinician email
Referring practice:
Reason for referral:
*
Elective
Urgent
Treatment Left
Consultation
Surgical extraction
Wis tooth extraction
Canine Exposure
Apicectomy
Treatment Middle
Biopsy
Facial Myalgia
Facial Pain
Implant Placement
Sinus Lift
Treatment Last
Bone Graft
IV sedation
Patch/Ulcer
Patient’s Forename
*
Patient’s Surname
*
DOB
Gender:
M
F
Patient’s Email Address
*
Patient’s Phone Number
*
Tooth/teeth to be extracted: *
Tooth/teeth to be extracted:
8
7
6
5
4
3
2
1
Bottom Left
8
7
6
5
4
3
2
1
Top Right
1
2
3
4
5
6
7
8
Bottom Right
1
2
3
4
5
6
7
8
Reason for extraction:
Medical History:
Allergies:
Alcohol units per week:
Smoker:
Yes
No
Additional Information:
Attached:
IOPA
OPG
CBCT
Clinical Photos
Ask Dr Alaa
Phone
Name
Telephone
Email
Enquiry
Privacy Consent
I consent to my data being used in accordance to the
Privacy Policy
*.
Marketing Consent
I consent to my personal data being collected and stored for the purpose of marketing communications.
Patients
Dentists
Read Now
Publications
Read More
Book Now
Procedures
Read More
View Now
Transformations
Read More
View on Instagram
About Mr Aldaadaa
Procedures
Transformations
Education
Publications
Referrals
Contact Me
Contact Me
