Patient Referral

Patient Referral

We offer a free initial consultation for your patients. Generally this is sufficient for us to discuss treatment options in broad terms and give approximate costings where possible. If you can provide relevant radiographs then this enables a more detailed discussion.

If your patient requests we will move to a comprehensive analysis from which we will present treatment options.

Thank you for your kind referral.

    Referring Dentist (required)

    Practice address

    Contact number(s)

    Email

    Patient name (required)

    Home address

    Contact number(s)

    Email

    Date of birth

    Do you want us to provide options for treatment that is:

    Full Mouth

    Full arch - Upper

    Full arch - Lower

    Localised - Teeth/gaps

    Is treatment urgent?

    Is the patient particularly anxious?

    Summary of problem

    Relevant dental history

    Relevant medical history

    Are you providing any other treatment for the patient?

    When would you like us to contact you?

    Before we meet the patient?After consultation and diagnosis?After treatment completed?At regular stages throughout treatment?

    Your email (Enter if you require a copy of the referral for your records)

    Attachments (e.g. X-rays)

    Once again, thank you for your kind referral