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Referral Form

To refer a patient to Stephen Frais Endodontics, please fill in all three sections below ensuring that you complete the required fields marked with a *

Dentist details
Patient details
Clinician's requirements
Tooth / teeth
You may optionally upload an X-ray image here. Please note that you can only send through images in the following formats: .gif, .jpg, .png or .zip (see below). The maximum file size you may upload is 3mb. If you wish to send through an image that is larger than 3mb in size, compress the image(s) into a zip file using windows or a 3rd party program such as Winzip and upload the zip file (please see Microsoft Zip File Guide for help).
Files must be less than 3 MB.
Allowed file types: gif jpg png zip.
You may optionally upload an X-ray image here. Please note that you can only send through images in the following formats: .gif, .jpg, .png or .zip (see below). The maximum file size you may upload is 3mb. If you wish to send through an image that is larger than 3mb in size, compress the image(s) into a zip file using windows or a 3rd party program such as Winzip and upload the zip file (please see Microsoft Zip File Guide for help).
Files must be less than 3 MB.
Allowed file types: gif jpg png zip.
You may optionally upload an X-ray image here. Please note that you can only send through images in the following formats: .gif, .jpg, .png or .zip (see below). The maximum file size you may upload is 3mb. If you wish to send through an image that is larger than 3mb in size, compress the image(s) into a zip file using windows or a 3rd party program such as Winzip and upload the zip file (please see Microsoft Zip File Guide for help).
Files must be less than 3 MB.
Allowed file types: gif jpg png zip.
You may optionally upload an X-ray image here. Please note that you can only send through images in the following formats: .gif, .jpg, .png or .zip (see below). The maximum file size you may upload is 3mb. If you wish to send through an image that is larger than 3mb in size, compress the image(s) into a zip file using windows or a 3rd party program such as Winzip and upload the zip file (please see Microsoft Zip File Guide for help).
Files must be less than 3 MB.
Allowed file types: gif jpg png zip.
You may optionally upload an X-ray image here. Please note that you can only send through images in the following formats: .gif, .jpg, .png or .zip (see below). The maximum file size you may upload is 3mb. If you wish to send through an image that is larger than 3mb in size, compress the image(s) into a zip file using windows or a 3rd party program such as Winzip and upload the zip file (please see Microsoft Zip File Guide for help).
Files must be less than 3 MB.
Allowed file types: gif jpg png zip.
You may optionally upload an X-ray image here. Please note that you can only send through images in the following formats: .gif, .jpg, .png or .zip (see below). The maximum file size you may upload is 3mb. If you wish to send through an image that is larger than 3mb in size, compress the image(s) into a zip file using windows or a 3rd party program such as Winzip and upload the zip file (please see Microsoft Zip File Guide for help).
Files must be less than 3 MB.
Allowed file types: gif jpg png zip.
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