Referral Form

I would like to refer my patient for: *

Orthodontic Consultation

Surgical Consultation

Braces for Teeth Alignment

Growth Check / Other Procedure

Referring Practitioner Practice Address *

Practice Name

Street Address

City

Post Code

Please enter a valid email for confirmation of referral and follow up communication

Patient Contact Telephone/Mobile Number *

Please enter a valid phone number. This will be our primary contact method for reaching your referred patient

Patient Contact Email *

Please enter a valid email address. This will be our secondary contact method for reaching your referred patient

Referral Information * Please tell us any information that will aid our diagnosis and planning for your referred patient

Relevant Medical Information Please provide any information on any medical concerns we should be aware of prior to patients first appointment (we will gather our own medical information at the first appointment)

Collaboration

I would like to be informed and involved in the treatment planning process prior to patient acceptance

I would like you to provide the service for which the patient has been referred and refer back to carry out further dental treatments if required

I wish for you to take over this case in its entirety then refer back for continuing health checks

Other

Clinical Records (Photos, Charts, Radiographs, Scans) Please upload any clinical records (if available) which would help in the diagnosis and treatment planning of your referred patient. Maximum 50mb. File types accepted pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif, stl, dicom. Additional information can also be sent to royalforthdental@gmail.com

Patient Referral Form