Referrals - Saving Faces

Referrals

Our team welcome patients attending the practice directly, or being referred by their own dentist.

Referring for a CBCT scan or OPG? See our CBCT and OPG referrals page for fees and how it works.

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

Patient Details

Patient Name*

First Last

Patient Date of birth*

Patient Address*

Address Line 1 Address Line 2 City County Postcode

Patient Contact Phone Number*

Patient Email

Type of referral

I am referring for*

Implant Case

Cosmetic Case

Oral Surgery

Orthodontics

Endodontics

Hygiene

OPG / Extra-Oral Bitewings

Cone Beam CT

Implant Referral*

Opinion Only

Surgical Placement / Uncovering

Full Case

Oral Surgery*

Retained Roots

Apicectomy

Other

Hygiene*

Routine S/P

Full Mouth Disinfection

Other

Charting

Teeth to treat*

Images

Radiograph or Image

Accepted file types: jpg, gif, tif, png, jpeg, Max. file size: 128 MB.

X-ray / CBCT Referral Details

Reason for referral and clinical justification for X-ray / CBCT scan*

Upper Arch Scan*

No Scan

Full Arch

Sectional

Lower Arch Scan*

No Scan

Full Arch

Sectional

If sectional view requested please state 4 teeth of most importance*

Define the anatomical area that the scan / x-ray should cover*

What information do you want the dental CBCT examination to provide?*

Patient to wear stent provided by dentist ?*

Yes

Positioning of splint*

I confirm the patient is competent in positioning splint

Due to the many different types of radiographic stents, it is essential that you ensure that your patient is competent in positioning it to your specifications.

IRMER

IRMER referrer/operator*

I am the IRMER referrer/operator. I am adequately trained to report on my patient’s scan. To comply with the IRMER 2000 regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We advise that all CT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology.

Referral Details

Patient Complaint / Reason for Referral*

Relevant Medical History

Dentist Details

Dentist Name*

First Last

GDC Number*

Dentist Email*

Referring Practice*

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