Patient Referral Form

Treatment Required

Please tick and specify details below in the box provided.

Enclosures

Please tick the supporting material you will be posting us. If you have any relevant radiographs, please so send them preferably by email. Enclosures can also be emailed to smile@onclinic.co.uk under separate cover. If emailing attachments (e.g. X-rays), as it will be non-secure, please omit patient's name but add the following details in the subject line: Patients initials, Patients Date of Birth, Referring Dentists Name.

Referrer Details

Additional Details For CT Scan Request

Examination Required (Parallel to occlusal plane unless requested otherwise)

Patient to wear stent provided by own dentist?

Format Required by Dentist

With Free Viewing software on Disc:

Please contact us to discuss other formats/software licence fees etc if required.
Scans are normally delivered within 7-10 days. Additional information on request.

Please tick if requesting a CT scan

(Click to read guidance notes)