PerioCare Dental Practice

Referral for Specialist Periodontal Care

PerioCare Dental Practice

Our Process

At PerioCare Dental we offer a referral service for patients in need of periodontal treatment in a relaxed environment, on an independent basis. We have modern facilities including digital radiography equipment, as well as laser-assisted gum disease treatment options.
Patients referred for periodontal care are requested to return to their referring clinician for any general dental treatment required, as well as their routine dental check-ups.

PerioCare Dental Practice

Patient Referral Form

Name of Referrer(Required)

Prefix First Last

Practice Name(Required)

Address(Required)

Street Address Address Line 2 Town County Postal Code Country

Phone Number(Required)

Email Address(Required)

Patient Name(Required)

Prefix First Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 Town County Postal Code Country

Contact Telephone Number(Required)

Patient Email Address

Service Required - Please Tick(Required)

Periodontal Assessment and Treatment

Implant Assessment and Treatment

Minor Oral Surgery Assessment and Treatment

Hygienist services

Other (Please provide details below)

Radiographs and documents

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Max. file size: 100 MB.

Comments and RMH(Required)

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Referral for Specialist Periodontal Care

Our Process

Patient Referral Form

Contact Us Today

020 8590 9900

07427 265620

[email protected]

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34A Barley Lane, Goodmayes, Ilford, Essex, IG3 8XF