Please fill out form if you are a patient.

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1
PATIENT FORM
NAMEyour full name
person
ADRESSyour address
home
DATE OF BIRTH
date_range
MOBILEMobile
stay_current_portrait
TELEPHONEHome
call
DENTIST’S NAME
person
DENTIST’S ADDRESSdentist's address
business
DENTIST’S TELEPHONEdentist's telephone
call
CHIEF COMPLAINT
CURRENT MEDICAL CONDITIONSmore details
0 /
CURRENT MEDICATIONmore details
0 /
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Please fill out form to refer a patient.

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1
REFERRAL FORM
REFERRING PRACTITIONER
NAMEyour full name
person
ADDRESSyour address
person
MOBILEMobile
stay_current_portrait
TELEPHONEHome
call
PATIENT
NAMEyour full name
person
ADDRESSyour address
home
MOBILEMobile
stay_current_portrait
TELEPHONEHome
call
CHIEF COMPLAINT
no-icon
REASON FOR REFERRAL:more details
0 /
CONSULTATION OR TREATMENT:more details
0 /
POST SPACE REQUIRED:(YES/NO)
RESTORATIVE STATUS OF TOOTH:more details
0 /
RELEVANT MEDICALS DETAILS:more details
0 /
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Please fill out form to request a callback.

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1
CONTACT FORM
NAME
person
TELEPHONEMobile
call
CHIEF COMPLAINTmore details
0 /
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Please fill out form to request an emergency discussion.

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1
24/7/365 EMERGENCY
NAMEyour full name
person
DATE OF BIRTH
date_range
MOBILEyour mobile number
stay_current_portrait
TELEPHONEMobile
call
DETAILSmore details
0 /
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Please fill out form to request an appointment cancellation (must be done 48 hours prior to appointment). Full appointment costs may be charged in failing to do this.

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1
CANCELLATION FORM
NAMEyour full name
person
DATE OF APPOINTMENT
date_range
MOBILEMobile
stay_current_portrait
TELEPHONEHome
call
CANCELLATION REASONmore details
0 /
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Consultation and Report

Your dentist may consider a referral for several reasons. Firstly, you may have a complex dental issue that requires specialised knowledge or advanced procedures which your dentist does not undertake regularly. Additionally, you may have presented with a rare or uncommon dental condition that requires specialised expertise for accurate diagnosis and treatment. Whatever the reason, we will assess and explain your dentists’ concerns and determine to what extent specialist management is required. We will prepare a report of the findings for you and your dentist outlining what has been discussed with recommendations on how best to proceed.

Consultation

  • Examine50%
  • X-Ray60%

Report

  • Review X-Ray50%
  • Review Treatment60%
£300 - £425.