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Referral Form
Referral Form
Referral Form
"
*
" indicates required fields
Step
1
of
3
33%
Referral for
*
Endodontics
Implants
Minor oral surgery
CBCT and OPT
Treating Clinician
*
Dr Usmaan F Majid BDS BSc MSc AssocFCGDent
Dr Faiz Khan BDS MFDS MSc PgDip
No preference
PATIENT DETAILS
Patient name
*
First
Last
Date of Birth
*
Day
Month
Year
Address
Street Address
Address Line 2
City
Postal Code
Phone
*
Email
*
CLINICIAN DETAILS
Dentist Name
*
First
Last
Practice Name
*
Address
Street Address
Address Line 2
City
Postal Code
Phone
*
Email
*
Reason for referral
*
Primary treatment
Retreatment
Advice or 2nd opinion
Reason for referral
*
Root removal
Third molar
Advice or 2nd opinion
Please select which services you require for this patient
*
OPT
CBCT
OPT Cost £50
What are the clinical indications and justification?
CBCT area of interest?
Please select
1. Upper left quadrant £150
2. Upper right quadrant £150
3. Lower left quadrant £150
4. Lower right quadrant £150
5. Maxilla £200
6. Mandible £200
7. Both jaws £250
CBCT will be emailed to the clinician in DICOM and Viewer formats
Case details
Please provide a brief history
NOTE: In some cases, if the treatment is deemed to be too complex, you may be asked to re-refer the patient to a specialist endodontist
Provisional diagnosis
Preferred core restoration
Amalgam
Composite
Temporary Material
Relevant medical history
Recent radiograph(s)
Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 64 MB.
Consent
The patient consents under the referral process to have an x-ray exposure and understand what it involves. I have provided the patient with adequate information related to the benefits and risks associated with the radiation dose. For children under the age of 16, the parent our guardian agrees
Signature
Checklist and Submission
Checklist (Endontic Referral)
Please tick to confirm the tooth is predictably restorable following endodontic treatment
A radiograph has been provided (if using wet film please post this with the paper version of this form)
The patient is aware of the private nature of this referral and has been informed of the estimated costs involved
The patient has been made aware there is a mandatory £55 consultation fee
Checklist (Implant Referral)
A radiograph has been provided (if using wet film please post this with the paper version of this form)
The patient is aware of the private nature of this referral and has been informed of the estimated costs involved
The patient has been made aware there is a mandatory £55 consultation fee
Checklist (Minor Oral Surgery Referral)
A radiograph has been provided (if using wet film please post this with the paper version of this form)
The patient is aware of the private nature of this referral and has been informed of the estimated costs involved
The patient has been made aware there is a mandatory £55 consultation fee
Signature
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