Referral form

Please complete the form below and click on the "send referral" button to send this information electronically to us.

Name

Address

Postcode

Telephone

Name

Address

Postcode

Date of birth (dd/mm/yyyy)

Daytime telephone

Evening telephone

Have we seen the patient before? Yes | No

Brief description of request

Is this request urgent? Yes | No

Preferred treatment location

Is the patient experiencing any of the following:

Pain

Swelling

Recurrent infection

Pericoronitis

Bad taste

Other symptoms

For apicectomy referrals, has the tooth been root-treated? Yes | No

Relevent medical history
(including allergies and current medications)

Is treatment to be carried out under intravenous sedation? Yes | No

Has patient any previous sedation experience? Yes | No

Will you be forwarding radiographs? more info Yes | No

Has the patient been informed of the likely costs?Yes | No

Other comments

Tim Milton