Referral Form

Patient Details

Title* —Please choose an option—MrMrsMsMissDrOther

Gender* —Please choose an option—FemaleMaleNon-binaryOther

First Name*

Last Name*

Address Line 1*

Address Line 2*

Address Line 3*

Address Line 4*

Post Code*

Date of Birth*

Patient Email Address*

Patient Telephone Number*

Patient Medical History*

Patient Dental History

Referring Dentist Details

Dentist Title —Please choose an option—DrMrMrsMsMissOther

Dentist Name*

Dentist Address Line 1*

Dentist Address Line 2*

Address Line 3*

Address Line 4*

Dentist Post Code*

Dentist Email Address*

Dentist Telephone Number*

Treatment Required

Consultation (all apical microsurgery & sedation appointments)Consultation & Investigation (e.g. restorability assessment, fractures, etc.)Primary EndodonticsSecondary (Re-Treatment) EndodonticsEndodontics (including correction of iatrogenic errors)Apical MicrosurgeryIV Sedation

Which endodontist?* —Please choose an option—Dr Sanjeev BhanderiDr Rob JacobsDr Shanil PatelAny Specialist

Tooth to be Assessed*

Is this an urgent case?* —Please choose an option—YesNo

Referral Notes* (e.g. relevant medical history)

Do you have any files you wish to attach in support of this referral? (Radiographs / Clinical Photos)*

Please upload files here.

Accepted file types: jpg, gif, png, pdf, tiff, docx, Max. file size: 15 MB.

NOTE: It is our pledge that ALL patients will be returned to your care at the end of treatment and we will NOT provide any non-essential treatment outside the remit of your referral without consulting you first.
For certain treatments we would like to recall the patient for a review and audit of our work. If it is more convenient for the patient (e.g. travelling distance) we may ask for your assistance to review your patient on our behalf.