Extraction Referral Form
PATIENT DETAILS
Patient's Name
*
First Name
Last Name
Patient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Phone Number
*
-
Area Code
Phone Number
Patient's Email
*
example@example.com
DENTIST / REFERRER DETAILS
Name (DENTIST / REFERRER)
*
First Name
Last Name
Address (DENTAL PRACTICE)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email (DENTIST)
*
example@example.com
Phone Number (DENTIST)
*
-
Area Code
Phone Number
Diagnosis
*
Reason For Referral
*
Have you discussed the reason for referral with the patient?
*
DENTIST / REFERRER DETAILS
*
Have you discussed the costs with the patient?
*
yes
no
File Upload (MHx, RAD)
*
Browse Files
Drag and drop files here
Choose a file
Please upload current medical history and appropriate radiographs (please include OPG if 3rd molar)
Cancel
of
You have made the patient aware of fees for:
*
Assessment / Consultation
Complex Extraction
Surgical Extraction
COSTS:
Consultation: £50 Wisdom Tooth Extraction £210 Surgical Extraction £320
Referral Checklist, please not incomplete referrals will be returned.
Completed referral form
Completed and recent medical history
Relevant radiographs
If printing: please send completed forms to:
Eilertsen Dental Care, Rhin House, 24 William Prance Road, Plymouth, PL6 5WR, EDC@eilertsen-dental.co.uk 01752 910 640
Submit
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