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Dentist Area Dentist Referral
Specialist Dental Referral
  1. Referring practitioner:

  2. Full Name(*)
    Please type your full name.
  3. Practice
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  4. Practice address
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  5. Postcode
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  6. E-mail(*)
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  7. Telephone(*)
    Please enter your telephone number
  8. Patient details:

  9. Full Name(*)
    Please enter the patients name
  10. D.O.B.
    Please select a date when we should contact you.
  11. Patient address
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  12. Telephone
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  13. Mobile
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  14. Email(*)
    Please enter a valid patient email
  15. Additional information
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  16. The following document/radiographs/notes are attached:

  17. Patient records
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  18. Radiographs (intra-oral)
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  19. Radiographs (pan-oral)
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  20. Tooth / Teeth to be treated (click as appropriate):

  21. Top Left








  22. Top Right








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  23. Bottom Left








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  24. Bottom Right








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  25. Extra information

  26. Pain
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  27. Swelling
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  28. Vital
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  29. PA Lesion
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  30. Discipline Required:

  31. Periodontics
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  32. Endodontics
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  33. Prosthodontics
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  34. Orthodontics
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  35. Oral surgery
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  36. Paedodontics/Special needs
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  37. Implantology
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  38. Invisalign (Complimentary)
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  39. Botox (Complimentary)
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  40. Reason for referral/patient complaint

  41. Reason
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  42. Medical history & Special precautions:

  43. Sedation required?
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  44. Is this case URGENT?
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  45. All patients who have been referred to Ethicare Dental will be returned to you on completion of treatment.You will be kept fully informed throughout your patients progress both at the consultation stage and following treatment. If your patient has been referred for consultation advice you will be contacted as soon as possible regarding this advice. If you have any concerns or questions or would like to discuss any aspect of your patients care with the specialist please do not hesitate to contact the practice.

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020 8870 5059