Tooth Doctor: Patient Referral Form

Relationship Building

We promise to work ethically with you and return your patient back to you. We will involve and inform you of your patient’s treatment every step of the way.

Support & Mentoring

We will support you and your dental clinic, mentor and help you develop your skills & CDP.

Patient Care

We will endeavour to treat your patients with the utmost care and diligence.

Treatment Referral
CT Scan Referral

Treatment Referral

Simply fill in the below form to refer a patient and one of our dentists will contact you to arrange further details.

Referring Practitioner

Practioner Name

Address

Telephone

Mobile

Your Email

Patient Details

Patient Name

Address

Patient Contact Number

Patient Alternative Contact Number

Patient Email

Date of Birth

Private Health Insurance
YesNo

Insurance Company

Referral Details

Referring
ImplantologyOrthodonticsEndodonticsCosmetic DentistryProsthodonticsHygienePeriodonticsPaediatric DentistryOral SurgeryIV SedationFacial TreatmentsInvisalignOther

Reason for referral

I would like to be present during the consultation/treatment
YesNo

I would like the dentist to contact me to discuss the case
YesNo

Relevant Medical History

Has the patient been given an estimate of our fees?
YesNo

Other Relevant Information

Documents

Upload any notes or X-rays here:

CT Scan Referral

Simply fill in the below form to refer a patient and one of our dentists will contact you to arrange further details.

Referring Practitioner

Practioner Name

Address

Telephone

Mobile

Your Email

Patient Details

Patient Name

Address

Patient Contact Number

Patient Alternative Contact Number

Patient Email

Date of Birth

Examination Required: (Parallel to occlusal plane unless requested otherwise)
CT MaxillaCT MandibleCT of both jawsPlease tick if you would like CT Maxilla to show 20+mm maxillary sinus (e.g. prior to sinus lift)

Patient to wear stent provided by own dentist? YesNo

Additional Information / Justification for Scan:

PLEASE NOTE:
Patient’s will be requested to make payment at the Scan appointment.
Please indicate if you prefer the referring practitioner to be invoiced

Community Dental Services: Dentist Referral

Relationship Building

Support & Mentoring

Patient Care

Treatment Referral

CT Scan Referral

Treatment Referral

Referring Practitioner

Patient Details

Referral Details

Documents

CT Scan Referral

Referring Practitioner

Patient Details

Basildon Clinic

Thurrock Clinic

Opening Hours

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