Referral Form

BYWAYS DENTAL REFERRAL FORM

To refer a Patient to us, please complete the form below with as many details as possible.


    Dr Raman Bhardwaj - Specialist Periodontist - Implant ConsultationPeriodontal Consultation


    Dr Pavan Gogna - Dentist with Special Interest in EndodonticsCBCT


    Dr Amita Gogna - Special Interest in Orthodontics


    Dr Pavan Gogna - Facial Aesthetics


    TREATMENT REQUIRED (Please enclose all relevant X-rays):



    Please tick box if your patient requires IV sedation for the dental procedure
    YesNo