Referral Form

Referral for*

Endodontics

Implants

Minor oral surgery

CBCT and OPT

PATIENT DETAILS

Patient name*

First Last

Date of Birth*

Day

Month

Year

Address

Street Address Address Line 2 City Postal Code

Phone*

Email*

CLINICIAN DETAILS

Dentist Name*

First Last

Practice Name*

Address

Street Address Address Line 2 City Postal Code

Phone*

Email*

Reason for referral*

Primary treatment

Retreatment

Advice or 2nd opinion

Apicectomy

Reason for referral*

Root removal

Third molar

Advice or 2nd opinion

Please select which services you require for this patient*

OPT

CBCT

OPT Cost £50

CBCT area of interest?

CBCT will be emailed to the clinician in DICOM and Viewer formats

What are the clinical indications and justification?

Case details

Please provide a brief history

NOTE: In some cases, if the treatment is deemed to be too complex, you may be asked to re-refer the patient to a specialist endodontist

Provisional diagnosis

Relevant medical history

Recent radiograph(s)

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 64 MB.

Consent

The patient consents under the referral process to have an x-ray exposure and understand what it involves. I have provided the patient with adequate information related to the benefits and risks associated with the radiation dose. For children under the age of 16, the parent our guardian agrees

Signature