Patient Referral Form
For Dentists, Doctors and Health Care Professionals to refer patients for our specialist services.
I would like to refer my patient for:
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Orthodontic Consultation
Implant Consultation
Sedation for Dental Treatment
Dental Radiograph (CBCT, Lateral Cephalometric, Panoramic)
Second Opinion or Advice
Other Dental/Surgical Procedure
Additional Information:
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Please detail the treatment type or procedure required.
Orthodontic Consultation Type:
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Private Orthodontics - (Patient is over 26 years of age and/or is IOTN grade 1, 2 or 3) - There is a fee of £150 for a new patient private orthodontic consultation which includes required clinical records (photos, radiographs, I/O scans)
NHS Orthodontics - (Patient is under 26 years of age and/or is IOTN grade 3, 4 or 5) - The is no fee payable by the patient
Second Opinion of Advice Type:
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I wish to ask a specialist practitioner to comment on my case using the clinical records uploaded - no appointment is required for the patient
I wish for my patient to have an assessment appointment booked (£65) for a specialist practitioner to write a report back to me to provide the recommend treatment
Dental Radiography Type:
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Panoramic (OPG)
Lateral Cephalometric
CBCT
CBCT additional information:
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Please detail the required area to be exposed and your justification for exposure.
Referring Practitioner Name
*
Dr.
Mr.
Mrs.
Ms.
Miss.
Prefix
First Name
Last Name
Referring Practitioner Practice Address
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Practice Name
Street Address
City
Post Code
Referring Practitioner Email
*
Please enter a valid email for confirmation of referral and follow up communication
Patient Details
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Mr.
Mrs.
Ms.
Mx.
Miss.
Master.
Dr.
Prefix
First Name
Last Name
Patient Date of Birth
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-
Day
-
Month
Year
Patient Address
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Street Address
Street Address Line 2
City
State / Province
Post Code
Patient Contact Telephone/Mobile Number
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Please enter a valid phone number. This will be our primary contact method for reaching your referred patient
Format: 00000000000.
Patient Contact Email
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Please enter a valid email address. This will be our secondary contact method for reaching your referred patient
Referral Information
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Please tell us any information that will aid our diagnosis and planning for your referred patient
Relevant Medical Information
Please provide any information on any medical concerns we should be aware of prior to patients first appointment (we will gather our own medical information at the first appointment)
Collaboration
I would like to be informed and involved in the treatment planning process prior to patient acceptance
I would like you to provide the service for which the patient has been referred and refer back to carry out further dental treatments if required
I wish for you to take over this case in its entirety then refer back for continuing dental health checks
Other
Clinical Records (Photos, Charts, Radiographs, Scans)
Browse Files
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Please upload any clinical records (if available) which would help in the diagnosis and treatment planning of your referred patient. Maximum 50mb. File types accepted pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif, stl, dicom. Additional information can also be sent to info@bitedentistry.co.uk
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