Self Referral FormHomeSelf Referral FormSelf Referral FormPlease enable JavaScript in your browser to complete this form.Patient DetailsName *FirstLastEmail *Telephone *We are a specialist-based practice treating periodontal disease and implants. Have you been referred to us by your dentist? *YesNoPlease provide the details of your dentist/dental practice: *If we need old x-rays and notes do you consent to us contacting your dentist for these? *YesNoIf yes to the question above, where would be the the best practice to contact? If no to the question above, leave blank.When did you last attend the dentist? *Less than 6 months agoSomewhere between 6-24 months agoMore than 2 years agoHave you seen a periodontist or received any gum treatment in the past? *YesNoIf yes to the question above, please provide any relevant details below.Do you have any dental implants? *YesNoIf you have implants that need attention, can you provide any records or recall any information of where, when, and by whom they were they placed, as well as what system was used? *YesNoIf yes to the question above, please provide any relevant details below.Who has been maintaining your implants with regular check-ups and cleanings since the implants were placed? *My own dentistDentist who provided the implantsNoneHave you experienced any pain or discomfort around the implant site since they were placed? *YesNoDo you notice any redness, swelling, bleeding pus or discharge around the implant site or difficulty on chewing or biting down on the implanted tooth/teeth? *YesNoNameSubmit
