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0333 443 4580
Home
Meet The Referral Team
Referral Services
Dental Implants
Endodontics
Inhalation Sedation
IV Sedation
Oral Surgery
Paediatric Dentistry
Periodontics
Prosthodontics
Orthodontics
Fees
Our Locations
Contact
Menu
Home
Meet The Referral Team
Referral Services
Dental Implants
Endodontics
Inhalation Sedation
IV Sedation
Oral Surgery
Paediatric Dentistry
Periodontics
Prosthodontics
Orthodontics
Fees
Our Locations
Contact
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The Sandstone Dental Practice
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The Sandstone Dental Practice
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The Sandstone Dental Practice
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The Sandstone Dental Practice
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The Sandstone Dental Practice
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The Sandstone Dental Practice
Refer a patient
The Sandstone Dental Practice
Refer a patient
The Sandstone Dental Practice
Refer a patient
Patient Referral Form
DIGITAL REFERRAL FORM 2021
Patient Details
Please provide the details of the patient you wish to refer
Name
*
Prefix
Mr
Mrs
Miss
Ms
Dr
Prof.
Rev.
First
Last
Address
*
Street Address
Address Line 2
City
Postal Code
Date of Birth
*
DD slash MM slash YYYY
Mobile Phone Number
*
Landline Phone Number
Email
*
Dentist Details
Please provide the details of the referring dentist.
Name
*
Prefix
Mr
Mrs
Miss
Ms
Dr
Prof.
Rev.
First
Last
Practice Name
*
Address
*
Street Address
Address Line 2
City
Postal Code
Home Phone Number
*
Mobile Number
Referrer Email
*
Referral Details
Please provide details of the referral you wish to make.
Please indicate the discipline the referral relates to:
*
Endodontics
Periodontics
Prosthodontics
Restorative Dentistry
Implants
Oral Surgery
Paediatric Dentistry
Aesthetic Dentistry
Orthodontics
Inhalation Sedation
IV Sedation
Imaging / Radiograph
Preferred Clinician for Endodontics
*
No Preference for Clinician
Miss Kate Blundell
Dr Obyda Essam
Dr Emad Moawad
Prof Fadi Jarad
Would you like us to carry out the definitive restoration (e.g. crown or onlay) at our practice?
*
Yes
No
Would you like us to place a direct core (& post if appropriate) prior to returning the patient back to your practice?
*
I intend to place the core myself and would prefer you to place a temporary restoration
Please place a direct core
Please place post and core if required
Referred to Periodontics
*
No Preference for Clinician
Prof Fadi Jarad
Dr Adejumoke Adeyemi
Referred to Prosthodontics
*
No Preference for Clinician
Prof Fadi Jarad
Referred to Restorative Dentistry
*
No Preference for Clinician
Prof Fadi Jarad
Referred to Implants
*
No Preference for Clinician
Fadi Jarad
Robbie Williams
Referred to Oral Surgery
*
No Preference for Clinician
Robbie Williams
Andrew Travers
Referred to Aesthetic Dentistry
*
No Preference for Clinician
Dr Chirag Patel
Referred to Paediatric Dentistry
*
No Preference for Clinician
Dr Sarah Longridge
Referred to Orthodontics Dentistry
*
No Preference for Clinician
Dr Sara Hosni
Referred to Inhalation Sedation
*
No Preference for Clinician
Dr Sarah Longridge
Referred to IV Sedation
*
No Preference for Clinician
Dr Giju George (Anesthetist)
Who would you prefer to provide restoration of the implant(s)?
*
Please restore the implant(s) at Referral Centre
Please send back to me for restoration
If the patient requests treatment on adjacent teeth at the same time as having implant treatment are you happy for this to be offered as part of the same treatment plan at our practice.
*
Yes, this is ok
No, please refer them back to me for further discussion
If it is deemed that the patient requires/would benefit from hygiene support prior to undertaking implant treatment, we will arrange for this to be done within our team at our Referral Centre. If you would prefer us to refer back to you for hygiene support prior to implant surgery, please let us know below
*
I am happy for my patient to have pre-operative hygiene support at our referral Centre
I would prefer for you to send the patient back to our practice for stabilisation
Following restoration of the implant, the patient will be discharged back to you for all ongoing care and maintenance. However, if you would like us to assist in providing ongoing implant maintenance support to the patient with our hygienist team into the future, we would be more than happy to. Is this something you would like us to offer to your patient on completion of treatment?
*
Yes please
No thank you, we will provide hygiene support within our own practice
Teeth chart
Please indicate which teeth the referral concerns.
Please indicate which teeth the referral concerns.
*
If tooth requires endodontic treatment and is not restorable
*
If the tooth that requires endodontic treatment and is not restorable, would you be happy for us to offer extraction and / or treatment to replace the tooth?
I am happy for you to offer further treatment
I would prefer to discuss and plan the next stage with the patient myself
Radiograph
Type of radiograph requested
*
2D
3D
Ceph
2D Radiograph Options
*
Standard
OPT
TMJ
L
R
OPT Bite Wing
Single
*
L
R
Type of radiograph requested
3D Radiograph Options
*
Full Dentition
Single Arch Maxilla
Single Arch Mandible
Sinus
Small FOV
OPT Bite Wing
Standard Definition
High Definition
Please specifiy area (Small FOV)
*
Ceph Radiograph Options
*
Lateral
Antero-Posterior
Clinical context for requesting the above examination
Relevant results of history, clinical examination, and other imaging
What information do you want the radiographic examination to provide?
Define the anatomical area that the radiograph should cover
Radiograph / Imaging Consent
*
*If, under the service level agreement images will be reported on by the referring practice unless otherwise specified above
The referring practice will then be responsible for ensuring the clinical evaluation takes place and is properly recorded.
I agree.
Relevant medical history (incl. smoking status)
*
Referral information
Please upload any relevant files
Drop files here or
Select files
Max. file size: 180 MB, Max. files: 6.
Enclosures
Please let us know if you have provided any additional information with this referral. We would be grateful if you would provide any relevant radiographs alongside your referral.
To reduce paper and improve efficiency, we would like to contact you by email with updates on your patient's treatment, please indicate if you would prefer an alternative means of contact
Happy to receive correspondence by email
I would prefer to receive correspondence by post
Other
Other (please specify)
Include in mailing list to keep you informed of any additional developments or CPD events run by our practice?
Yes
