Referral Form


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87654321

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12345678

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87654321

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12345678



non surgical root canal therapy requiredsurgical root canal therapy requiredre-treatment of previous root canal therapy requiredemergency treatment will be required


nitrous oxideoral sedationIV sedationgeneral anaesthesia

temporarilypermanently


yesno

yesno

yes


yesno

To the best of my knowledge, the above information is correct:


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