Please tick the appropriate referral: *

ENDODONTICS
Mr Cesar Muñoz-Villena
Practice Limited to Endodontics
DDS MSc (Endodontics)
GDC: 208309

PERIODONTICS
Ms Dimitra E Tsarouchi
Specialist in Periodontics
BDS(Lond), MClinDent (UCL),
CertPerio (EFP), MRD RCS (Eng)
GDC: 103982

IMPLANTS
Ms Deborah Bomfim
Consultant & Specialist in Restorative Dentistry,
Clinical Lecturer in Restorative Dentistry
BDS, MSc (UCL), MJDF RCS (Eng),
FDS (Rest Dent) RCS (Eng)
GDC:103979

ORTHODONTICS
Ms Sara Stephens
Specialist & Consultant Orthodontist
BDS, MJDF RCS (Eng), MClinDent Orth (Distinction),
MOrth RCS (Eng), FDS (Orth) RCS (Eng)
GDC:103298

ORAL SURGERY
Ms Ayse Nazli Spencer
Specialist Oral Surgeon
BDS (Lond) MJDF RCS(Eng),
GCAP M.Oral Surg
GDC:104084

FIXED PROSTHODONTICS
Ms Irene Kaimakamis
Principal Dentist, Special Interest in Fixed Prosthodontics,
Honorary Speciality Dentist King’s College Dental Hospital
BDS, MJDF RCS (Eng),
MSc (UCL)
GDC:104215

HYGIENE
Ms Meranda Gomez-Adams
Dental Hygienist Therapist
DipDH DipDT RCS (Eng),
BSc (Hons)
GDC: 258289

Patient Details: *

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

Surname:

Forename(s):

Date of Birth:

Address:

Postcode:

Tel/Mobile:

Email:

Reason for Referral: *

ConsultationSecond Opinion onlyTreatment

Please give as much detail as possible and include any treatment already carried out:

For Endodontic Referral Only:

Is the Patient in pain? YesNo
Final restoration to provided by Dr Munoz?YesNo
If yes, would you like: CompositeAmalgamPreparation post spaceFiber postMetal post

Enclosures (Please tick):

PeriapicalsOPG/DPTCone beam CTBitewingsPhotographsSix Point Probing ChartOther (Please Specify Below)

(Please note that enclosing good quality radiographs will speed up the referral process)

Upload here:

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Relevant Medical History: *

Practice Details: *

Referring Practitioner:

Referring Practice:

Practice Address:

Post Code:

Telephone:

Email: