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Secure Referral Forms

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Patient Details

Patient's Address*
DD slash MM slash YYYY

Referring Dentist's Details

Practice Address*

Please select the type of referral

Orthodontic Referral

Need for treatment - IOTN Score

Please select from the relevant sections below to add more information.

Oral Surgery / Implants Referral

Treatment Request
Relevant Xrays

Endodontics Referral

Treatment Required*
Previous Treatment

CBCT OPG Referral

Fees collected directly from the patient

Referral Requirements

The referring dentist is responsible for supplying us sufficient information to justify the appropriate exposure.
2D field of view required*
Exposure*
CBCT 3D View*
5x5cm (sectional)*

Facial Aesthetics Referral

Treatments
Dermal fillers
Skin Boosters
An initial consultation with a dentist will be required. Cost of consultation £50 which is deductible from treatment costs

Attachments

Do you have files to upload for this referral?*
Please Include Any Relevant File Attachment such as Radiographs, Clinical Notes Or Photographs
Drop files here or
Accepted file types: jpg, pdf, doc, docx, png, Max. file size: 512 MB.
    Be assured that we advise patients to continue seeing their own dental practitioner for their regular routine examinations and treatment.

    Declaration *

    By submitting this form you declare that you

    Declaration - Personal Data*
    Declaration - Patient Aware*
    Clear Signature
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