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Refer a patient
Ph: 03 355 1445
Fax: 03 962 1325

office@perioservices.co.nz

Refer a patient

Patient Name

Patient date of birth - dd/mm/yyyy

Patient Address

Patient Phone

Patient Mobile

Relevant medical history

Referring dentist/hygienist

Generalised periodontitis

Localised periodontitis

Tooth/Teeth

Gingival recession

Tooth/Teeth

Crown lengthening

Tooth/Teeth

Implant:

Implant:

Straumann

Nobel Biocare

Biomet 3i

Osstem

Tooth/Teeth

Extraction and Ridge Preservation (Location)

Tooth/Teeth

ACC

Claim number

Date of injury - dd/mm/yyyy

Other

Other details

Comments

Additional information (i.e x-rays or photos)

Please send additional files or images as PDF or JPEG

File 1

File 2

File 3

Contact Details

Ph: 03 355 1445

Fax: 03 962 1325

154 Leinster Road,
Merivale, Christchurch 8014

Connect with us

Home
About
Services
FAQs
Ph: 03 355 1445

Fax: 03 962 1325

E: office@perioservices.co.nz

154 Leinster Road,
Merivale, Christchurch 8014