Referrals

Referrals

Phone

This field is for validation purposes and should be left unchanged.

Patient Details

Patient Name(Required)

Title First Last

Patient Date of birth(Required)

Day

Month

Year

Patient Address(Required)

Address Line 1 Address Line 2 City County Postcode

Patient Email(Required)

Patient Contact Phone Number(Required)

Type of referral

I am referring for(Required)

Implant Case

Endodontics

Advanced Restorative / Tooth Wear

TMD

Has the tooth being replaced been extracted?(Required)

Yes

Date of extraction(Required)

DD slash MM slash YYYY

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This case

Is Urgent

Requires IV Sedation

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Implant Referral

Opinion Only

Surgical Placement / Uncovering

Oral Surgery(Required)

Retained Roots

Apicectomy

Wisdom Teeth

Other

Charting

Teeth to treat(Required)

UR8

UR7

UR6

UR5

UR4

UR3

UR2

UR1

UL1

UL2

UL3

UL4

UL5

UL6

UL7

UL8

LR8

LR7

LR6

LR5

LR4

LR3

LR2

LR1

LL1

LL2

LL3

LL4

LL5

LL6

LL7

LL8

Radiograph or Image

Drop files here or

Accepted file types: jpg, gif, tif, png, jpeg, Max. file size: 128 MB, Max. files: 5.

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Referral Download PDF

CBCT Referral Details

Reason for referral and clinical justification for CBCT scan(Required)

If sectional view requested please state 4 teeth of most importance(Required)

Define the anatomical area that the scan should cover(Required)

What information do you want the dental CBCT examination to provide?(Required)

Patient to wear stent provided by dentist ?(Required)

Yes

Positioning of splint(Required)

I confirm the patient is competent in positioning splint

Due to the many different types of radiographic stents, it is essential that you ensure that your patient is competent in positioning it to your specifications.

IRMER Compliance

IRMER referrer/operator(Required)

I am the IRMER referrer/operator. I am adequately trained to report on my patient’s scan. To comply with the IRMER 2000 regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We advise that all CT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology.

Further Details

Patient Complaint / Reason for Referral(Required)

Relevant Medical History

Smoker(Required)

Yes

Dentist Details

Dentist Name(Required)

Title First Last

Practice / Dentist Email(Required)

GDC Number(Required)

Practice Address(Required)

Street Address City Postcode

CAPTCHA

A PDF copy of the referral will be available to download immediately following submission.

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Patient Details

Type of referral

Charting

CBCT Referral Details

IRMER Compliance

Further Details

Dentist Details

Tottington

Ramsbottom

Monday - Friday Closed for lunch	9.00am - 5.30pm 1.00pm - 2.00pm
Extended opening in Tottington on Thursdays	8.00am - 8.00pm