Refer to us

We are happy to welcome all referrals to help you manage the needs of your patients. Patients will be cared for professionally by our friendly specialist dental team and returned to the referring dentist upon completion of treatment. We will keep referring dentists fully informed of the progress of their patients’ care.

 

Our promise to you… ALL patients will be returned to your care after completion of treatment. NO patients will be allowed to be taken on for their general dental care at the practice. NO treatment other than that referred for will be carried out without the express permission of the referring dentist.

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Patient’s Details

First Name of patient *

Surname of patient *

Gender of patient *

MaleFemale

Date of birth of patient *

Address *

Contact Number *


Patient’s Details

Name of referring dentist *

Name of referring practice *

Practice phone number *

E-mail address *

Date this patient registered *

Patient's dental plan

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Patient history and treatment required

Treatment required *

Type of care required *

Status of condition (tick all that apply)

SwellingPulp exposed and bleedingDressing and temporary filling insertedTooth opening for drainageEndodontic treatment startedElective endodontic treatmentPermanent bridge/crown is cementedPatient has discomfort

If your condition is not listed above, please give details below

Is condition urgent? *

YesNo

Please give any more details

Dental treatment given to date

Relevant medical history

Patient history and treatment required

Permission to perform further treatment if required? *

YesNo

Please give any more details

Have radiographs been taken? *

YesNo

Will radiographs be sent separately (by email or post)?

YesNo

Do you wish radiographs to be returned?

YesNo

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