Skip to main content

Referral

Fields with * are mandatory.

    Referral dental office

     

    Referring dental practice*

    Referring dentist*

    Street/No*

    Postcode/City*

    Phone number*

    E-Mail-Address*

     

    Patient information

     

    First name (Patient)*

    Last name (Patient)*

    Street/No (Patient)*

    Postcode/City (Patient)*

    Phone (Patient)*

    E-Mail-Address (Patient)

     

    Desired treatment

     

    Tooth/s No.*

    Root canal treatmentRoot canal re-treatmentApical microsurgery

    Therapy urgency*
    urgentnot urgent

    Attachment 1 (X-ray photograph etc.)

    Attachment 2 (X-ray photograph etc.)

    Other comments

     

    Address

    Practice Dr. med. dent. George Sirtes
    Eidg. dipl. Zahnarzt SSO
    Lindenhofstrasse 17
    8001 Zurich
     info@drsirtes.com
    +41 44 211 54 44

    Hours of operation

    Monday to Thursday
    08:30 to 17:30 h

    Friday
    08:30 to 14:30 h

    © Dr. med. dent. George Sirtes

    Privacy policy | Site notice