ORAL SURGERY REFERRAL (GDP USE ONLY)

Referrals

This form is for a General Dental Professional only.

While we aim to contact you as soon as possible, please allow 24-48 hours for a response.

Referring Dentist Name

GDC Number

Referring Dental Practice

Referring Dentist Contact

Patient Name

Date of Birth required

Patient Contact Number

Patient Email

If other please specify here

Urgency

Routine

Urgent (within 7 days)

Emergency (same day / 24 hours)

Medical history checked and upto date

Yes

No

Relevant medical conditions

Anticoagulants / bisphosphonate / other risks

Allergies

Supporting Clinical Images and Radiographs

Upload File

Upload supported file (Max 15MB)

Declaration Required

Patient consent has been given for the referral

I confirm this patient is aware the treatment is private

I confirm I will continue the patients ongoing dental care

Thanks for submitting!