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Referral Form

Please use this form to send on line referrals to the practice.
A PDF version of the form is available as a download. Click here.

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Referring practitioner

Name:

Practice:

Address:

Phone:

Fax:

Mobile:

e-mail:

Patient details

Name:

Address:

Phone:

Fax:

Mobile:

e-mail:

Date of birth:

Referral for

Endodontics Urgent?

Implants Urgent?

Orthodontics Urgent?

Periodontics Urgent?

Prostodontics Urgent?

Restorative dentistry Urgent?

Surgical dentistry Urgent?

Other (please state):

Referral details

Purpose of referral:

Patients main complaint

Documents

Small documents can be uploaded here. If you are intending to send us documents over 2MB in size please send them seperately via email by clicking this link.

Document 1

Document 2

Document 3

Document 4

Patient records

Uploaded here Sent via email Sent via post Please return

Consent form

Uploaded here Sent via email Sent via post Please return

Study models

Uploaded here Sent via email Sent via post Please return

Radiograph: Intra-oral

Uploaded here Sent via email Sent via post Please return

Radiograph: Panoral

Uploaded here Sent via email Sent via post Please return

Dental history

Uploaded here Sent via email Sent via post Please return

Patient condition

Oral condition:

Periodontal state:

Missing teeth:

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

Pain:

Swelling:

Other relevant information:

Dental implants
Crown & Bridge
Endodontics
Dental hygiene
Mentoring support
Orthodontic
Periodontal
Crown Lengthening Course – Saturday 29th February 2020

Our specialists

Dr Michael Hodgson BDS MGDS RCS (Eng) Specialist in Prosthodontics
Dr Neil Millington MSc BChD MGDS RCS (Eng) Specialist in Prosthodontics
Dr José Zurdo LMS BMS MSc Cert.Perio (Gothenburg) Specialist in Periodontics
Dr Jason Bedford BDS MDentSci MFDS RCPSG Specialist in Endodontics
Dr Andrew Flett BDS, MJDF RCS (Eng), MClinDent (Sheffield), MOrth RCS (Eng),FDS (Orth) RCS (Eng) Consultant Orthodontist
Dr Cristina Romao LMD Portugal, MSc (Gothenburg Sweden) Specialist in Periodontics

Referral dentists

Dr Jeremy McCahill MSc BChD (Leeds), MSc Implant Dentistry (Distinction) General Dental Practitioner
Dr Fiona Phillips LDS RCS (Eng) BDS DPDS General Dental Practitioner

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General dental care
Improving your smile Prosthodontics
Dental implants solutions for missing teeth
Endodontics root canal treatment
Orthodontics the treatment of misaligned teeth
Periodontics – Gum Disease treatment of gum disease
Sedation for anxious patients or patients who have a sensitive gag reflex

Partners:
Dr Michael Hodgson BDS MGDS RCS (Eng) Specialist in Prosthodontics
Dr Jeremy McCahill MSc BChD (Leeds), MSc Implant Dentistry (Distinction) General Dental Practitioner
Dr Neil Millington MSc BChD MGDS RCS (Eng) Specialist in Prosthodontics
Dr Fiona Phillips LDS RCS (Eng) BDS DPDS General Dental Practitioner
Dr José Zurdo LMS BMS MSc Cert.Perio (Gothenburg) Specialist in Periodontics

© 2020 The Carisbrooke Specialist Dental Centre, 238 London Rd, Leicester, LE2 1RL | appointments@carisbrookedental.co.uk | Tel: 0116 270 7030
Registered in England & Wales: OC380942