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Referrals
Referral form

Patient details (step 1)

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First name *

Last name *

Address 1 *

Address 2 *

Postcode *

Date of birth *

Contact number *

Email *

Please check that the following fields have been filled out correctly:

Referring Dentist Details (step 2)

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First name *

Last name *

Phone number *

Practice name *

Practice address line 1 *

Practice address line 2

Practice city *

Practice county *

Practice postcode *

Email address *

Please check that the following fields have been filled out correctly:

Referral Details (step 3)

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Enter the name of the relevant clinician to refer your patient to (if known)

Treatment required *

Reason for referral/treatment required. Please detail relevant dental history and preferred clinician if applicable

General assessment of dental health

Oral hygiene *

Poor Fair Good Other

Teeth of poor prognosis *

Relevant medical history *

Additional files
- Please note that only the following file types are supported: jpeg, jpg, png, gif, pdf, doc, docx, xls, xlsx, rtf, ppt, odt.

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Other records sent via post

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Final restoration to be placed by:

The Referring Dentist By 23 Cosmetic Dental & Implant Clinic

Any comments

Confirmation

I confirm I have the requisite authority to share the patient's information in connection with this referral

Please check that the following fields have been filled out correctly:

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23 Cosmetic Dental & Implant Clinic is a trading name of Portman Healthcare Limited registered in England and Wales: 06740579. Registered office: Rosehill, New Barn Lane, Cheltenham, Glos, GL52 3LZ.
Portman Healthcare Ltd is authorised and regulated by the Financial Conduct Authority and is the broker and not the lender. Our FCA registration number is 700090. Portman Healthcare Ltd offers credit products from Secure Trust Bank PLC trading as V12 Retail Finance. Credit is provided subject to affordability, age, and status. Minimum spend applies. Not all products offered by Secure Trust Bank PLC are regulated by the Financial Conduct Authority. Portman Healthcare Limited is the controller of your data and registered with the Information Commissioners Office under registration number Z1929449

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Last updated 13/08/2024 at 16:24

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