020 8870 5059
020 8870 5059

Dentist Referral

  • Referring practitioner:

  • Patient details:

  • The following document/radiographs/notes are attached:

  • Tooth / Teeth to be treated (click as appropriate):

  • Top Left

    TL8 TL7 TL6 TL5 TL4 TL3 TL2 TL1

    Top Right

    TR1 TR2 TR3 TR4 TR5 TR6 TR7 TR8

    Bottom Left

    BL8 BL7 BL6 BL5 BL4 BL3 BL2 BL1

    Bottom Right

    BR1 BR2 BR3 BR4 BR5 BR6 BR7 BR8
  • Extra Information:

  • 0 + ++ +++

  • 0 + ++ +++

  • Yes No

  • Yes No

  • Discipline Required:

  • Reason for referral/patient complaint:

  • Medical history & Special precautions:

  • Yes No

  • Yes No

  • All patients who have been referred to Ethicare Dental will be returned to you on completion of treatment.You will be kept fully informed throughout your patients progress both at the consultation stage and following treatment. If your patient has been referred for consultation advice you will be contacted as soon as possible regarding this advice. If you have any concerns or questions or would like to discuss any aspect of your patients care with the specialist please do not hesitate to contact the practice.

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