Referral Form - Longwood House Dental Care

Referral Form
o Dental Implants
o Endodontics
o Clear Brace Orthodontics (Adults/Teens)
o Childrens Specialist Teatment
o Treatment with IV/IS Sedation
o Oral Surgery
o Specialist Periodontist
o TMJ/HeadAche/Snoring
o Request for Referral Forms
Longwood House
Dental Implant & Specialist Referral Practice
150 Longwood Gardens,
Ilford, Essex IG5 0BE
[email protected]
www.longwood-house.co.uk
T: 020 8551 0088
F: 020 8551 4100
M: 07957 925350
Most consultation fees are refundable on uptake of treatment - Please refer to the Fee Guide for details. We thank you for your referral.
Following treatment all patients will be referred back to their own practitioner for continual care. If further assistance is required, please do not
hesitate to contact us. Please post/fax the referral form to Dr T Ahmed, or refer online by logging on to www.longwood-house.co.uk
Referring Practioner Details
Name:
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Practice address: ………………………………………………………………………………………………………………………………………………………………………………………………………
Postcode:
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Telephone: ………………………………………………………………………………………………………………………………………………………………………………………………………………………
Patient Details
Name:…………………………………………………………………………………………………………………………………D.O.B:
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Patient address: …………………………………………………………………………………………………………………………………………………………………………………………………………
Postcode:
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Telephone:………………………………………………………………………………………………………………………Mobile:
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Email: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Relevant medical history: ………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Reason for referral
o Patient Consultation Only
o Treatment Planning Assistance
Please enclose most recent x-ray, this will be returned following the completion to treatment
o Assessment & Treatment
Other relevant information/enclosure ie Radiograph: …………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Practitioners signature: ………………………………………………………………………………………………Date:
……………………………………………………………………………
Dr Tasleem Ahmed BDS FDS RCS (Eng) - Principal Dentist Longwood House, Clinical Lecturer Kings College (GKT), Award Winning Dentist
Child Referral - Parent Information
At Longwood House we have a children’s specialist dentist, and hope that you and your patients find this service
of use. I will appreciate it if your parents could read through the script below prior to attending with their child.
“Why do we need Specialist dental care for our child?"
There are not many dentists specialising in children’s dentistry. Many specialists work in the hospital where your child
may wait up to a month to be seen. Your child is being referred to a specialist in order to have treatment or advice
regarding their dental development. Your dentist may not have all the resources required for specialist treatment.
The Specialist at Longwood House is Dr P. Anand - She is also working as the Consultant Paediatric Dentist at The
Eastmans Dental Hospital in London. You will need to attend a first consultation with your child for a full assessment
and treatment planning. You will be contacted in the next few days, and appointments are usually made for the
weekend. The consultation Fee is taken at the time of booking, so please have your card at hand.
Children scared of the dentist’s chair will benefit seeing a specialist, as your child will be treated very gently
and there will be lot’s of TLC.
Many parents believe that children’s first dentition is not important and a loss of a tooth is ‘OK.’ This is simply not true.
Decay and poor dental development has a profound impact on the development of your Childs adult teeth. Extraction
of teeth at a young age create an imbalance, causing the adult set of teeth to come through in a ‘crooked’ manor.
To then have these teeth straightened means further extractions of adult teeth are then unavoidable. A dental abscess
left untreated or poorly treated can also damage and weaken the developing adult teeth.
Your dentist may refer your child to a specialist in order to avoid treatment under general anaesthetic (as this carries
a great risk to your Childs general well being). The Specialist can occasionally “win” your child over, build up their
confidence and alleviate their anxiety; thus on many occasions General Anaesthesia can be avoided. It is always worth
exploring this route! For those children requiring difficult treatment or have a fear of dentistry, the specialist can use
“Happy Gas” (nitrous oxide) as it is a safe, short acting and an efficient way to relieve anxiety in a child. IV sedation is
also available for children over 10yrs. The aim is to provide gentle and pain free treatment and build up a positive
attitude towards dentistry.
The Specialist will discuss all aspects of your Childs treatment needs with you and your general dentist and provide her
expert professional opinion. She will also undertake surgery for children; extractions, frenectomy, orthodontic
extractions and exposures.
“It is important to maintain the first set of teeth in order to ensure healthier and stronger adult teeth for
your child.”
The consultation will be for 45 to 60 min - cost £140. The basic charge for treatments is £70 per half hour, this
includes basic fillings. Other special costs will be discussed at the consultation. Once treatment is completed you will
be referred back to your practitioner for general after care. (You may be required to reattend once every 1 or 2 years
for maintenance).
To avoid any delay, you may wish to contact us directly to arrange an appointment on 020 8551 0088.
(If the referral is of an urgent nature, evening appointments can be arranged - a call out fee will apply).
Meet Our Dentists
Dr Tasleem Ahmed
BDS FDS RCS (Eng)
GDC Number: 69865 Date Qualified: 2003
Dr Ahmed is a clinical teacher in restorative dentistry,working part time at the world renowned Guy`s Hospital, London.
She is also a Fellow of The Royal College of Surgeons and a Member of The British Academy of Cosmetic Dentists.
She is a highly experienced clinician, providing General Dentistry, Dental Implants, Clear Brace Orthodontics and
Smile MakeOvers.
Dr Prabhleen S Anand
BDS MMedSc, FDSRCS (Eng), MPaedDent, FDSC (Paed Dent)
GDC Number: 81513 Date Qualified: 2003
Prabhleen is a Specialist in Paediatric (Childrens Dentistry and Oral Surgery). She is currently a Consultant in Paediatric
Dentistry at The Eastmans Dental Institute. Longwood House is proud to be the only local dental practice able to offer
a specialist childrens service.
Dr Anina Chapman
MBChB (Stellenbosch)
GMC Number: 4508296 Date Qualified: 2009
Dr Chapman graduated as a medical practitioner from the University of Stellenbosch and has worked in hospital
anaesthetics in South Africa. She works with Dr Ahmed to alleviate anxiety in the nervous dental patient. She also
is an experienced clinician in providing facial aesthetic, botox and filler treatments in The Anti-Ageing Clinic at
Longwood House.
Dr Jesus Molina
BDS IQE MFDS RCSEdin MSc
GDC Number: 118100 Date Qualified: 2009
Practice limited to endodontics. He is a member of the Royal College of Surgeons of Edinburgh and was awarded
distinction in his masters degree at the Eastmans Dental Institute. He accepts referrals for Endodontic (root canal)
treatments from the regional dental practices, as well as providing in house service to the patients of Longwood House.
Dr Marina Arzoumanidi
DDS, MclinDent Periodontology - Periodontist
GDC Number: 84611 Date Qualified: 2004
Dr. Marina graduated in Dentistry from Athens University and worked afterwards as a general dentist in London. She then
undertook the three year full time training programme in Periodontology at the prestigious Eastman Dental Hospital in
London. She is currently working as a Specialist Periodontist.
Fee Guide
Dental Implant Consultation
Dental Implant (Astra/Nobel) ……from £2,200 surgery & crown
Paediatric (Childrens) Consultation with specialist …………
………………………………………………………………………………………………£140
Bone Grafting
Basic Treatment ………………………………………………£70 per half hour
£35 refundable
…………………………
………………………………………………………from
£1,200
With Inhalation Sedation
Teeth Straightening/Smile Makeover Consultation ………
…………………………………………………………………………………£35 refundable
A range of discrete clear brace appliances can be used to
straighten the teeth quickly and efficiently. Inman Aligner,
Invisalign, Clearstep, 6 Month Smile.
Periodontist Consultation with Specialist
£120
[Only suitable for children >10 years old]
Treatments with GA can be arranged.
Oral Surgery Consultation ………………………………£35 refundable
Patients with BUPA medical insurance can receive treatments
under GA free.
………………
Non surgical treatment ……………………………from £250 - £300
Surgical treatment, flap surgery, grafting,
frenectomy, recession treatments ………………………from £350
Endodontist Consultation
£100 per hour
…………………………………
With IV Sedation …………………………………………………£150 per hour
£35 refundable
Sedation
Inhalation Sedation for Adults
………………from
£100 per hour
IV Sedation charge for Adults…………………from £150 per hour
Single Root Treatment ……………………………………………from £450
Anti Snoring, Head Ache and TMJ Dysfunction
Consultation …………………………………………………………£35 refundable
Multiple Root Treatment…………………………………………from £580
(Tanner/CRA)
Re Root Canal molar Treatment …………………………from £680
Anti snoring appliance
………………………………
……………………………………………………………from
…………………………………………from
The above fees are set as a guide for your patients, all patients will receive a final cost at the consultation phase.
We do offer credit/ finance for treatments over £400
£680
£350
About Our Practice
Longwood House Dental Implant & Specialist Referral practice is an established dental referral clinic with a
comprehensive list of services that can be offered to your patients as an extension to your own services.
Our aim is to ensure you also receive advice and support from the team of dentists at Longwood House,
as we are contactable directly by e-mail or over the phone. We also welcome you and your dental team
to join our regular Verifiable CPD events, which are held throughout the year - many of which are free.
(Please see our website for further event details).
Longwood House are an Award winning practice with status of BDA Good Practice. The practice conforms
to CQC standards of patient care, health & safety and data protection: and all staff members undertake
regular CPD - and many are Specialists or Experts in their field. At Longwood House, we have made a
pledge to provide affordable private dentistry without compromising the quality your patients receive.
Referring to the practice is easy:
• You or your patients may call us on 020 8551 0088 to arrange an appointment.
We will need a completed referral form for your patient
• Fax the referral form to 020 8551 4100
• E-mail the referral form to us at [email protected]
• Refer online via our website www.longwood-house.co.uk you may attach x-rays to the referral.
• Send your referral by post
We wish to welcome you to the Longwood House Dental Implant & Specialist Referral Practice and we
look forward to hearing from you.