Referral form

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Referral form

Patient details (step 1)

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First name *

Last name *

Address 1 *

Address 2 *

Postcode *

Date of birth *

Contact number *

Email *

Please check that the following fields have been filled out correctly:

Referring Dentist Details (step 2)

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First name *

Last name *

Phone number *

Practice name *

Practice address line 1 *

Practice address line 2

Practice city *

Practice county *

Practice postcode *

Email address *

Please check that the following fields have been filled out correctly:

Referral Details (step 3)

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Enter the name of the relevant clinician to refer your patient to (if known)

Treatment required *

Reason for referral/treatment required. Please detail relevant dental history and preferred clinician if applicable

General assessment of dental health

Oral hygiene *

Poor Fair Good Other

Teeth of poor prognosis *

Relevant medical history *

Additional files
- Please note that only the following file types are supported: jpeg, jpg, png, gif, pdf, doc, docx, xls, xlsx, rtf, ppt, odt.

Other records sent via post

Radiographs Study models Diagnostic wax up None Other

Final restoration to be placed by:

The Referring Dentist By Station House Dental & Implant Clinic

Any comments

Confirmation

I confirm I have the requisite authority to share the patient's information in connection with this referral

Please check that the following fields have been filled out correctly:

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Station House Dental & Implant Clinic and Portman Dental Care are trading names of Portman Healthcare Ltd, registered in England and Wales: 06740579. Registered office: Rosehill, New Barn Lane, Cheltenham, Glos, GL52 3LZ. Portman Healthcare Ltd is authorised and regulated by the Financial Conduct Authority as a credit broker under registration number 700090. Credit is subject to status and affordability, and is provided by Novuna Personal Finance a trading style of Mitsubishi HC Capital UK PLC. Terms & Conditions Apply. Portman Healthcare Limited is the controller of your data and registered with the Information Commissioners Office under registration number Z1929449

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Last updated 07/05/2020 at 12:33

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