Referral Form

Referral for*

Endodontics

Implants

Minor oral surgery

PATIENT DETAILS

Patient name*

First Last

Date of Birth*

Address

Street Address Address Line 2 City Postal Code

Phone*

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

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.

Checklist and Submission

Checklist (Endontic Referral)

A radiograph has been provided

The patient is aware of the private nature of this referral

The patient has been made aware there is a mandatory £50 consultation fee

Checklist (Implant Referral)

A radiograph has been provided

The patient is aware of the private nature of this referral

The patient has been made aware there is a mandatory £50 consultation fee

Checklist (Minor Oral Surgery Referral)

A radiograph has been provided

The patient is aware of the private nature of this referral

The patient has been made aware there is a mandatory £50 consultation fee

Referral Form

PATIENT DETAILS

CLINICIAN DETAILS

Checklist and Submission

Services