Dental Referrals

Referral Form

Thank you for referring your patient to us for treatment. Please complete and submit the form below. We will contact you again after we have completed the initial consultation.


Patients Details

Referrer Details

Other Details

Radiographs/Images

Radiographs to follow?

YesNo


Digital Radiographs/Images uploaded?

YesNo


Radiograph/image upload 1


Radiograph/image upload 2


Radiograph/image upload 3


Radiograph/image upload 4


Radiograph/image upload 5


CT Referral Form

Please complete the form below in full and submit. We will contact your patient for an appointment.

Patients Details

Referrer Details

Scan Details

Area to be scanned

MaxillaMandible


Type of Scan


4cm x 4cm scan area £140

YesNo

Covers smaller areas e.g. wisdom teeth, TMJ’s, unerupted canines and cysts.


8cm x 8cm scan area £310

YesNo

Covers whole mandible and maxilla. Suitable for assessment of bone levels and nerve position prior to implant surgery.


The images are forwarded for reporting by the referring practitioner on a memory stick. We are pleased to assist in opening the files on the practitioner’s own computer.



Data Protection

We take your and the privacy of our patients very seriously and have policies, procedures and the infrastructure in place to protect any information and documents provided to us. We are fully complaint with the GDPR legislation and other applicable data protection regulations. For more information, please click here to view our full privacy policy.