Dentist Referrals

• Dentist information

• Referring dentist:
• Address:
• Telephone:
• Fax:
• Email*:

• Patient information

• Patient name:
• Address:
• Date of birth:
• Telephone Number:
• Email:
• Have we seen the patient before? No Yes
• Has the patient been informed of the likely costs? No Yes
• Patient prefers contact by:
  • Email:
  • Post:

Treatment information

• Tooth number:
• Has the tooth been root filled before? No Yes
• Consultation or Treatment?
  • Consultation only
  • Treatment
• Please indicate the patients symptoms by ticking the appropriate boxes:
  • Bad taste:
  • Bleeding:
  • Difficulty chewing:
  • Pain:
  • Recurrent abscesses:
  • Swelling:
  • Tooth mobility:
• Other symptoms:
• Other comments/reason for referral:

• Post and core:
  (To be completed at the clinic)
  • Yes:
  • No:
• Treatment required under sedation: No Yes
• Any relevant medical history:
• Relevant attachments e.g. radiographs:
• Relevant attachments e.g. radiographs:
• Relevant attachments e.g. radiographs:
• Relevant attachments e.g. radiographs:

Before clicking 'Send Referral', please ensure that a valid email address has been entered in the dentist 'Email' field above. This is so that we can send you confirmation that the referral has been sent.