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Referrals Service

If you as a dentist want to refer a patient to us for a cosmetic- and reconstructive dentistry and dental implants. Fill in the form below or call us on number +48 512 104 415.

 

Patient's information:
   
Name:
Telephone:
E-mail:
   
 
Clinic's information:
   
Name:
Clinic:
Address:
Telephone:
E-mail:
   


Information:




Please enclose pictures, x-rays and others:

   
   
   
   

 

 

 

 
 
         
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