Referrals

If you have someone to refer to us, please fill out the form below.

Referral Form

Implant Referral

Implant Referral Form

Referring Practice Details

Dentist Name

GDC Number

Practice Name

Practice Address

Address Line 1

Address Line 2

City

Postcode

Contact Telephone

Contact Email

Patient Details

Patient First Name

Patient Last Name

Patient DOB

Address

Address Line 1

Address Line 2

City

Postcode

Contact Telephone

Medical History

Dental History

Details of Request

CBCT/OPG Referral

CBCT/OPG Referral Form

Referring Practice Details

Dentist Name

GDC Number

Practice Name

Practice Address

Address Line 1

Address Line 2

City

Postcode

Contact Telephone

Contact Email

Patient Details

Patient First Name

Patient Last Name

Patient DOB

Address

Address Line 1

Address Line 2

City

Postcode

Contact Telephone

Medical History

Patient possibly pregnant?

Yes

Dental History

Referral Type

CBCT

OPG

Reason for referral and justification for the scan

CBCT areas of interest

Mandible

Maxilla

Both Jaws

In accordance with IR(ME)R 2000 a clinical justification must be provided for each dental CBCT scan and the scan must be clinically evaluated by someone trained in the analysis of dental CBCT scans.

I fully understand that SR Dental Care does not report on scans or OPG’S and it is the referring dentists responsibility to arrange this.

Please confirm if radiographic stent is required for CBCT

Yes

Special instruction/ Further Notes

Please note images will be sent via email. What is your preferred email address to send scan to?

Referrals and Appointment Booking

Appointment booking requests must be accompanied by a fully completed referral form. Referrals will be rejected if the referral form is missing or incomplete. It is the responsibility of the Referring Practice to ensure that referral forms are received at least 48 hours prior to the scheduled appointment time.

Please let your patient know the cost of the CBCT is £110 and a deposit of £50 will be taken at time of booking

SR Dental Care

0131 660 1315

info@srdentalcare.co.uk

25A South Street, Dalkeith, EH22 1AH

SR Dental Care | Registered Address: 25A South Street, Dalkeith, EH22 1AH