Referrals - The South Street Dental Practice

Referrals

We welcome referrals from dentists on a private basis. A PDF copy of the referral will be available for download on submission.

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Patient Details

Patient Name(Required)

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)

If under 18 please provide name of guardian

Type of referral

I am referring for(Required)

Orthodontics

Oral Surgery

Implant Case

Periodontal Care

Implant Referral(Required)

Opinion Only

Bone Grafting / Sinus Elevation / Soft Tissue Correction

Surgical Placement / Uncovering

Full Case

Oral Surgery(Required)

Retained Roots

Apicectomy

Wisdom Teeth

Other

Orthodontics

Orthodontic diagnoses

Please tick all that apply

crowding

increased overjet

increased overbite

anterior open bite

missing teeth

impacted teeth

reverse overjet

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

Radiographs / Images

Radiograph or Image

Drop files here or

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

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)

Smoker?(Required)

Yes

Relevant Medical History

Dentist Details

Dentist Name(Required)

First Last

Dentist Email(Required)

GDC Number(Required)

Practice Details(Required)

More Information

Patient Portal
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Standards for the Dental Team

Complaints Policy
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Opening Hours

Monday	8.30am – 5.30pm
Tuesday	8.30am – 5.30pm
Wednesday	8.30am – 5.30pm
Thursday	8.30am – 5.30pm
Friday	8.30am – 5.30pm

Please note we are closed for lunch between 1.00pm and 2.00pm Monday – Friday

Telephone: 01343 542729
Address: 16 South St, Elgin IV30 1LE