Referring Dentist Details
Practice name
*
Dentist name
*
GDC Number
*
Practice telephone
*
Format: (00000) 000000.
Mobile telephone
*
Format: (00000) 000000.
Email
*
example@example.com
Date of referral
/
Day
/
Month
Year
Date
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Patient Details
Patient's name
*
First Name
Last Name
Date of birth
*
/
Day
/
Month
Year
Date
First line of address
*
City
*
Postcode
Telephone number
*
Format: (00000) 000000.
Mobile telephone
*
Format: (00000) 000000.
Email
*
example@example.com
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Medical Details
Is the patient nervous about having dental treatment?
*
Yes
No
May we contact the patient to arrange an initial consultation appointment?
*
Yes
No
Relevant medical history
*
None
Arthritis
Osteoporosis
Receiving treatment from hospital doctor or clinic
Blood or bleeding disorder
Taking any prescribed/ non-prescribed medication
Infectious diseases (hepatitis)
Pregnant or possibly pregnant
Liver disease
Carrying a medical warning card
Heart disease
Bronchitis, asthma or other chest complaint
Pace maker
Blood pressure
Diabetes
Mental health or emotional issues
Other
Relevant medical history (to enter more than 1 item press 'Ctrl' whilst selecting)
None
Arthritis
Osteoporosis
Receiving treatment from hospital doctor or clinic
Blood or bleeding disorder
Taking any prescribed/ non-prescribed medication
Infectious diseases (hepatitis)
Pregnant or possibly pregnant
Liver disease
Carrying a medical warning card
Heart disease
Bronchitis, asthma or other chest complaint
Pace maker
Blood pressure
Diabetes
Mental health or emotional issues
Other
Medical History
Please provide full details of condition and medications
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Referral Details
Reason(s) for referral
*
CT Scan
OPG
Dental Implant(s)
Root Canal Treatment
Sinus Lift/ Bone Graft(s)
Extraction/ Biopsy
Complex Restorative Case
Dentures
Laser Treatment
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Referral Details
More detailed information
Do you have any relevant radiographs?
Yes
No
Please upload (Up to 5mb total)
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of
Areas to be treated
Rows
UR
LR
LL
UL
8
7
6
5
4
3
2
1
CBCT Details
Area of interest:
Please Select
Both Jaws (8 x 8 cm)
Maxilla (8 x 5 cm)
Mandible (8 x 5 cm)
Quadrant - Endo (5 x 5 cm)
Teeth to be scanned
Patient to bring radiographic template?
Yes
No
Radiographic template type
Denture marked
Seperate template
Clinical Indication
Justification for CBCT:
Please Select
Implants
Endodontics
Sinus Exam
TMJ
Bone Graft
Impacted Teeth
Other
Please provide details
CBCT Format
DICOM files
CBCT Output
Email
CD-ROM
Digital impression required? (STL file - additional £75 per arch)
Yes
No
Please upload any relevant files
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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OUR PROMISE TO YOU
We will only treat patients based on the issue(s) they have been referred to US for. If your patient requires additional treatment, we will speak to you in the first instance, to ensure that you remain central to all their treatment needs.
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