Patient Referrals to The Dental Article

First Name

Last Name

Practice Address

Practice Mobile Number

Practice Telephone Number

Practice Email

Full Name

Biological Gender

Date Of Birth

Patient Address

Patient Post Code

Patient Mobile Number

Patient Telephone Number

Patient Email Address

Parent/Guardian/Carer Name

Relationship to Patient

Has the patient consented to information sharing with other healthcare professionals where necessary?

Yes No

Please give details of the referral and please include any treatment already carried out/proposed.

Please attach any relevant documents (img.pdf/doc) on return of this file.

Urgency / Priority (Timescales if relevant)

Patient-specific Needs (special requirements/anxiety or cooperation (if relevant)

Date of Referral

Signature of Referrer (Typed Name)

Please confirm you remain responsible for the patient’s care while waiting.

Yes, I confirm

Please indicate whether, after treatment, the patient should be discharged back to your care.

Yes No

If you require CBCT please confirm below so SLA agreement can be emailed to you. Otherwise, select NO

Yes (send SLA Agreement) No

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