Referrals form | Bloxham Smiles

Referring Dentist Details

Referring Dentist Name

Practice Name:

Practice Address:

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Practice Email:

Practice Phone Number:

Patient Details

Patient Full Name:

Date of Birth:

Patient Phone Number:

Patient Email:

Address:

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Treatment Type:

Endodontics (Root Canal Treatment)

Implants

Oral Surgery

Restorative (Smile design,Crowns, Bridges, Veneers, etc.)

Composite Bonding

Invisalign

Clinical Information

Reason for Referral / Summary of Case:

Relevant Medical History:

Tooth/Teeth Involved (if applicable):

Radiographs / Images Upload:

Max. file size: 2 GB.

Additional Notes or Requests:

Preferred Contact Method

Phone

Contact the Patient Directly

Consent

I confirm that the patient has consented to this referral and the sharing of their clinical information with Bloxdent Smiles

Part of your patients recommended treatment plan may include hygiene services. Please tick this box if you DO NOT want Bloxdent Smiles to complete this as part of the patient’s overall treatment plan