507 referral form

Select a treatment *

Endodontic

Oral surgery

Periodontics

Dental implants

Dentist information

Referring dentist *

Address *

Telephone number *

Mobile number *

Fax

Email *

Patient name *

Patient address *

Patient telephone number *

Patient mobile number *

Patient email *

Patient date of birth *

Have we seen this patient before? Yes No

Has the patient been informed of the likely costs? Yes No

Patient prefers to contact by? Email Post Telephone

Tooth numbers *

Reason for referral *

Do you wish us to do the post and core if one is required? * Yes No

Pain? * Yes No

If yes, how severe is the pain?

Swelling? * Yes No

Has the tooth been root filled before? * Yes No

Consultation only? * Yes No

Treatment? * Yes No

Please indicate the patients symptoms by ticking the appropriate boxes *

Difficulty chewing

Recurring abscesses

Tooth mobility

Other symptoms

Treatment under sedation? * Yes No

Any relevant medical history? *

Relevant attachments e.g. radiographs