Referring a Patient
Title
*
Mr
Miss
Mrs
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
NHS Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Phone Number
Email
example@example.com
Translater Needed
*
Yes
No
Has a copy of the referral been given to the practitioner?
*
Yes
No
Details of Referring Practioner
Name
*
First Name
Last Name
Practice Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
Phone Number
Reason for Referral
Treatment
Routine
Advice
Urgency
Details of The Problem
*
Condition, Diagnosis and Clinical Circumstances
Dental & Medical History
Relevant dental, medical and drug history
Additional Note
Please use this space for any additional requirements
I clarify that...
Required
*
I have discussed the commitment required to undertake orthodontic treatment with the patient and the patient is highly motivated and prepared to wear appliances.
Required
*
The patient has good oral hygiene and no active disease.
Required
*
I have provided preventive advice and treatment where necessary for the patient and will continue to do so through orthodontic treatment.
Required
*
I will work with the orthodontist to enable treatment to be progressed including the extraction of teeth where necessary and preventive/restorative work as required.
Submit
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