Dental treatment referral form

To refer a patient to Sharrow Vale Dental Care, simply complete and submit the following referral form.
Please include all relevant clinical information and remember to attached any x-rays if relevant.
We will contact the patient to introduce ourselves and book them in. You will be kept fully updated on you patient's progress throughout.

Date of referral

Referring dentist's name

GDC number (optional)

Practice name

Practice address

Practice phone number

Practice email address

Referring dentist's mobile (optional)

Patient details

Title ---MrMrsMissMsDrProfRev

First Name

Surname

Daytime phone

Mobile

Email

Patient address

Street address

Address line 2

City

Postcode

Date of Birth

Relevant medical history

Tooth / Teeth to be treated

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Is this an implant referral? please specify

Is this an oral surgery / surgical extraction referral? Please specify

Is this an intravenous sedation referral? YesNo

Is this an Invisalign referral? YesNo

Is this an Inman Aligner referral? YesNo

Is this an endodontic referral? YesNo

Does the patient have pain / swelling? None / MinimalModerateSevere

Is this a primary case YesNo

Has an attempt at canal negotiation already been made? YesNo

Is this a root canal re-treatment case? YesNo

Do you have additional information you would like to add to this referral?

I certify that the information provided on this referral form is accurate to the best of my knowledge, and that the patient has consented to onward referral for the provision of specialist treatment/services from Sharrow Vale Dental Care Yes

I confirm that the patient has given consent to be contacted by Sharrow Vale Dental Care Via telephoneVia telephone & letterVia telephone, letter & email

Referring dentist's signature

Image upload