Referral Procedure

When we receive your referral request after you submit the form below; your patient will be contacted to make an appointment. The initial consultation will take 30 minutes and will consist of medical and social background information, to assess the extent of the patient’s problem. All the options and choices open to the patient will be discussed in detail with patient. If it is a particularly complex case a further visit may be necessary as well taking study models or even a CT scan at the practice.

Simply fill in your patients details below When the patient is ready to proceed with treatment we will make all the necessary appointments. During treatment is always reminded of the necessity of continuing to visit you for their general dental regular and treatment.

Referring Dentist Details

Referring Dentist Name ^*

First

Last

Practice Name ^*

Referring Dentist GDC Number ^*

Referring Dentist Email ^*

Referring Dentist Phone^*

Referring Practice Address^*

Reason For Referral^*

Your Patient Case History / Reason For CT Scan^*

Your Patient Details

Patient Name ^*

First

Last

Patient Email

Patient Mobile ^*

Patient Work Phone

Patient Home Phone

Referral Date^*

Patient Gender^*

Patients Address^*

Patient Date of Birth^*

Radiographs & Scans

You can attach your patients radiographs & scans below. Alternatively you can send them with your patient.

Select An Option^*

Attach Radiograph files or supporting documents here:

Drop files here or

SELECT FILES

Acceptable file types: jpg, jpeg, png, gif, pdf, doc, docx, ppt, pptx

Maximum file size: 3mb

Referral Procedure

Referring Dentist Details

Your Patient Details

Radiographs & Scans

“I attended today to have a large filling sorted out. I am extremely anxious with dentist visits, but the time the dentist took to reassure me and check on me throughout the procedure was fantastic and made all the difference for me.”

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