Endodontist - Alan Holland - Bristol Endodontic Clinic - Root Fillings Specialist bristol - Endodontic Specialist

Please note the referrals page is for use by the dental profession only.

Please fill in the form below and click on the 'Send Referral' button to send the information electronically to us.

Dentist Information

REFERRING DENTIST
ADDRESS
TELEPHONE
FAX
EMAIL

Patient Information

PATIENTS NAME
ADDRESS
DATE OF BIRTH
DAYTIME TELEPHONE
EVENING TELEPHONE
EMAIL
HAVE WE SEEN THE PATIENT BEFORE?	YES NO
HAS THE PATIENT BEEN INFORMED OF THE LIKELY COSTS?	YES NO

Treatment Information

TOOTH NUMBER

HAS THE TOOTH BEEN ROOT FILLED BEFORE?

YES NO

CONSULTATION ONLY

TREATMENT

PLEASE INDICATE THE PATIENTS SYMPTOMS BY TICKING THE APPROPRIATE BOXES.

BAD TASTE

BLEEDING

DIFFICULTY CHEWING

PAIN

RECURRENT ABSCESSES

SWELLING

TOOTH MOBILITY

OTHER SYMPTOMS

OTHER COMMENTS / REASON FOR REFERRAL

ANTIBIOTIC COVER REQUIRED?

YES NO

TREATMENT REQUIED UNDER SEDATION

YES NO

ANY RELEVANT MEDICAL HISTORY

Personal Details - Alan Holland

L.D.S. R.C.S. (London) 1977
B.Ch.D. (Leeds) 1978
M.Sc.Cons (Eastman) 1980

Endodontic Specialist Register June 1999

Lecture and Hands-on Courses throughout the UK.
Published articles in several dental journals.
Endodontic Referral Practice since 1990.

Bristol Endodontic Clinic January 2000.