41-43 VIVIAN AVENUEHENDON NW4 3UX Tel: 0208 202 7038 Email - hendon@dentalartsstudio.co.uk
Patient details
Medical History
Non-Smoker Smoker Ex-smoker
Dental History
Reason for referral
Previous treatment completed
Supra-gingival scale Sub-gingival scaling with local anaesthetic Date of last course
Referring Dentist
Thank you for your kind referral