Patient Details

    Title*

    Gender*

    First Name*

    Last Name*

    Address Line 1*

    Address Line 2*

    Address Line 3*

    Address Line 4*

    Post Code*

    Date of Birth*

    Patient Email Address*

    Patient Telephone Number*

    Patient Medical History*

    Patient Dental History

    Referring Dentist Details

    Dentist Title

    Dentist Name*

    Dentist Address Line 1*

    Dentist Address Line 2*

    Address Line 3*

    Address Line 4*

    Dentist Post Code*

     

    Dentist Email Address*

    Dentist Telephone Number*

    Treatment Required

    Which endodontist?*

     

    Tooth to be Assessed*

     

    Is this an urgent case?*

     

    Referral Notes* (e.g. relevant medical history)

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


    Please upload files here.

    Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 24 MB.


    NOTE: 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 for a review and audit of our work. If it is more convenient for the patient (e.g. travelling distance) we may ask for your assistance to review your patient on our behalf.