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Referrals
Referral form

Make a referral

To refer a patient to Church Road Dental Practice, simply complete and submit the below referral form.

Please include all relevant clinical information regarding this case, and remember to attached any x-rays if relevant.

After reviewing, we will contact the patient to introduce ourselves and book them in. We will also keep you fully updated on progress throughout.

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.

Other records sent via post

Radiographs Study models Diagnostic wax up None Other

Final restoration to be placed by:

The Referring Dentist By Church Road Dental Practice

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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Church Road Dental Practice and Portman Dental Care are trading names of Portman Healthcare Ltd, 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 as a credit broker under registration number 700090. Credit is subject to status and affordability, and is provided by Novuna Personal Finance a trading style of Mitsubishi HC Capital UK PLC. Terms & Conditions Apply. Portman Healthcare Limited is the controller of your data and registered with the Information Commissioners Office under registration number Z1929449

*The cost of £349 applies to the Boutique Whitening full kit - 4 x 3ml, at home teeth-whitening treatment and does not apply to any other whitening products available at the practice. Cost includes an initial consultation, custom-made whitening trays, whitening gel and a post-treatment appointment. Teeth whitening treatment is for over 18s only and patients must be dentally fit with a recent dental health check-up. Any dental health check-up and/or treatment required to make a patient dentally fit will be charged at an additional cost. Please note that the practice accepts no liability on behalf of the treating clinician and acts strictly as a liaison between the patient and the treating clinician only. The practice reserves the right to withdraw or change this product at this price from time to time. Full details available in practice.

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Last updated 05/12/2022 at 14:21

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