Online consultation

Please use this form if you wish to enquire re a certain topic or wish to know what may be possible in terms of treatment. Please note that this online consultation is NOT a substitute for a full clinical examination and advice is only given in broad terms. Treatment must not be be based solely on the information given from this online consultation.
Fields marked with an asterisk (*) must be completed to enable us to process the form.
First Name*
Last Name*
Contact number
How did you hear about us?
What are your concerns?
Broken tooth/fillings
Loose/lost crown
Old crowns
Bleeding gums
Wisdom teeth
Gum disease
Missing teeth
Protruding teeth
Crowded teeth
Dark tooth
Patient status
Other comments that will help us with your query
I am interested in:
Cosmetic fillings
Gum treatment
Filling a gap
Wisdom teeth removal
Tooth whitening
Please tell us what your concerns are and what you would like to change
If you would like to upload any photos to help illustrate your problem please do so here.

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Please note: All photographs submitted will be kept strictly confidential and not shared with any third party.
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