Refer a patient to College Street Dental & Implant Clinic | College Street Dental | Burnham

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Referrals
Referral Form

Make a referral

To refer a patient to College Street Dental & Implant Clinic, simply complete and submit the below referral form.

Please include all relevant clinical information regarding this case, and remember to attached any x-rays if relevant.

After reviewing, we will contact the patient to introduce ourselves and book them in. We will also keep you fully updated on progress throughout.

Patient details (step 1)

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First name *

Last name *

Address 1 *

Address 2 *

Postcode *

Date of birth *

Contact number *

Email *

Please check that the following fields have been filled out correctly:

Referring Dentist Details (step 2)

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First name *

Last name *

Phone number *

Practice name *

Practice address line 1 *

Practice address line 2

Practice city *

Practice county *

Practice postcode *

Email address *

Please check that the following fields have been filled out correctly:

Referral Details (step 3)

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Enter the name of the relevant clinician to refer your patient to (if known)

Treatment required *

Reason for referral/treatment required. Please detail relevant dental history and preferred clinician if applicable

General assessment of dental health

Oral hygiene *

Poor Fair Good Other

Teeth of poor prognosis *

Relevant medical history *

Additional files
- Please note that only the following file types are supported: jpeg, jpg, png, gif, pdf, doc, docx, xls, xlsx, rtf, ppt, odt.

Other records sent via post

Radiographs Study models Diagnostic wax up None Other

Final restoration to be placed by:

The Referring Dentist By College Street Dental & Implant Clinic

Any comments

Confirmation

I confirm I have the requisite authority to share the patient's information in connection with this referral

Please check that the following fields have been filled out correctly:

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College Street Dental & Implant Clinic and Portman Dental Care are trading names of Portman Healthcare Ltd, registered in England and Wales: 06740579. Registered office: Rosehill, New Barn Lane, Cheltenham, Glos, GL52 3LZ. Portman Healthcare Ltd is authorised and regulated by the Financial Conduct Authority as a credit broker under registration number 700090. Credit is subject to status and affordability, and is provided by Novuna Personal Finance a trading style of Mitsubishi HC Capital UK PLC. Terms & Conditions Apply. Portman Healthcare Limited is the controller of your data and registered with the Information Commissioners Office under registration number Z1929449

*This offer is valid from 25.11.24 to 10.01.25 and you must attend your initial appointment within this period. This offer is open to people aged 18 and over only, and cannot be used in conjunction with any other offer.This offer can only be redeemed once per person and is non-exchangeable, non-transferable, and is not redeemable for cash or other treatments. Please note that College Street Dental & Implant Clinic accepts no liability on behalf of the treating clinician and acts strictly as a liaison between the patient and the treating clinician only. College Street Dental & Implant Clinic has the right to remove or change the offer at any time. Any additional treatment or dental health check-up required to make a patient dentally fit will be charged at an additional cost.

Copyright © 2024 Portman Healthcare. All rights reserved.

Last updated 01/11/2024 at 15:37

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