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*
urgentoccasionally

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