Patient Referral Form

Patient Phone Number

Patient Date of Birth

Patient Gender

Male Female

Referring Dentist's Details

Referring Dentist Email Address

Dentist's Phone Number

Referring Speciality

Have you screened the patient for sleep apnoea?

Yes No

Do you have any files you wish to attach in support of this referral? (Radiographs / Clinical Photos)

Yes No

Further information enclosed

Xrays CT Scan Study Models Photographs

File Attachment Please include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF

NOTE: Prior to or during complex treatment, we may co-ordinate hygienist appointments in-house. For implant patients, due to the risk of peri-implantitis, it is normally a condition of our guarantee that the patient sees an implant-trained hygienist at prescribed intervals during the course of their treatment and for 12 months subsequently. Our guarantee is one year for the titanium implant screw and for the crown or bridge.

It is our pledge that ALL patients will be returned to your care at the end of treatment and we will NOT provide any non-essential treatment outside the remit of your referral without consulting you first.

For certain treatments we would like to recall the patient at yearly intervals for a review and audit of our work.

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