Facial Aesthetics Referral

You can make a referral in 3 ways:

1) Via Email:

– Click here to download our Referral Form

– Fill out all the required fields marked (*)

– Attach the Referral Form with any supporting xrays/images/charts and send to info@kdentalstudios.co.uk

2) Via Post:

– Click here to download our Referral Form

– Fill out all the required fields marked (*)

– Please send your Referral Form with any supporting xrays/images/charts to: 116 Great Portland Street, London, W1W 6PJ

3) Online Form: (compatible only with computer users)

– Please fill out the form below and click on send ensuring that you have filled out all

the required fields marked with (*)

Please tick the appropriate referral: *


Dr Gurjinder Kaur Rooprai
Associate Dentist, Interest in Facial Aesthetics
DDS MSc (Endodontics)
GDC: 208309

Patient Details: *

Title: Miss/Mrs/Mr/Dr/Other:

Surname:

Forename(s):

Date of Birth:

Address:

Postcode:

Tel/Mobile:

Email:

Reason for Referral: *

Previous History of Facial Aesthetics Treatment(s):*

Please give as much detail as possible:

Treatment(s) of Interest: (please tick one or more)

BOTULINUM TOXIN
DERMAL FILLERS

Enclosures (Please tick):

Upload here:


(Maximum upload filesize: 5Mb)

Relevant Medical History: *

Practice Details: *

Referring Practitioner:

Referring Practice:

Practice Address:

Post Code:

Telephone:

Email: