Patient Self-Referral Form Your provider of expert Oral Surgery care. We cater for self-referred patients, dentist referrals, and dental practices that want to boost their in-house offering Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth DD/MM/YYYY Email of Additional Contact NumberEmail *AddressPostcodeService RequiredApicectomyComplex ExtractionCoronectomyExpose and Bond of Impacted Tooth with Gold ChainFraenectomyOpen Exposure of Impacted ToothRemoval of Ectopic ToothSpecific Tooth/Teeth Requiring Treatment (if known)Do you require intravenous sedation?YesNoAdditional Notes (Optional)Submit Request