Extraction Referral Form

Extraction Referral Form

Use this form to refer for adult extractions or surgical treatments.
PATIENT DETAILS
Patient's Name *

First NameLast Name
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Phone Number*

Area CodePhone Number
Patient's Email*
example@example.com
DENTIST / REFERRER DETAILS
Name (DENTIST / REFERRER)*

First NameLast Name
Address (DENTAL PRACTICE) *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email (DENTIST)*
example@example.com
Phone Number (DENTIST) *

Area CodePhone Number
Diagnosis*
Reason For Referral *
Have you discussed the reason for referral with the patient?*
Have you discussed the costs with the patient?*

yesno
FEES:

Consultation: £50
CBCT: £150
IV Sedation £250 (per session)
Wisdom Tooth Extraction: £210 (Per tooth)
Surgical Extraction: £350 (Per tooth)
Operculectomy (£157 per site)
Socket preservation (£457 per site)
Bone grafting (price on planning)
Soft tissue grafting (price on planning)
You have made the patient aware of fees for:*

Assessment / ConsultationComplex/ wisdom tooth ExtractionSurgical ExtractionIV sedationOther treatment
Referral Checklist, please not incomplete referrals will be returned.

Completed referral formCompleted and recent medical historyRelevant radiographs
File Upload (MHx, RAD)*

Please upload current medical history and appropriate radiographs (please include OPG if 3rd molar)
Cancelof
Sign here:

Clear
If printing: please send completed forms to:

Eilertsen Dental Care, Rhin House, 24 William Prance Road, Plymouth, PL6 5WR, a.turner@eilertsen-dental.co.uk 01752 910 640
Should be Empty:

Extraction Referral Form

PATIENT DETAILS

DENTIST / REFERRER DETAILS

If printing: please send completed forms to: