Referral Form

Patient Details

• Title:
• Full Name:
• Address
• Postcode
• Tel Number:
• Work/Mobile:
• Email
• Date of Birth
• Medical History
• Current Medication
• Allergies

Reason for referral

• Treatment under Intravenous Sedation
• Surgical Extraction
  • Extensively Broken Down
  • Previous Root Canal Treatment
  • Associated Lesion
  • Failed Extraction
  • Retained Root
  • Multiple Retained Roots
• Consultation for Apicectomy
• Consultation for Third Molar Teeth
• Consultation for Soft Tissue Lesion
• Consultation for Implant(s)
• Consultation for TMJ/Facial Pain

Referring Practitioner's Details

• Dentist's Name
• Dentist Email
• Clinical Finding
• Radiographs Enclosed
  OPG Peri-apical Films Other

Uploads

Please use the upload facility to send any x-rays, photos or documents that are relevant for this patient (10mb max per upload).

• Upload 1
• Upload 2
• Upload 3
• Upload 4