We are committed to providing high-quality specialist care and will return your patient to your practice following completion of treatment.
Practice Name
Referring Dentist
GDC Number
Patient Address
Practice Address
Telephone *
Email *
Full Name *
Date of birth
Patient Telephone *
Patient Email
Treatment Required (please tick) *
Complex Root Canal TreatmentsPeriodontologyComposite BondingCone Beam Computed Tomography (CBCT) Scan
Tooth/Area concerned:
Relevant clinical details:
Medical History considerations:
Is the patient aware of this referral?
YesNo
Radiographs / Files
Sent with patientSent by emailTo follow
Additional Notes
Unit 4, Bower Shopping Complex, Pollard Road, Bridgwater TA6 4YA
01278-327-259
info@orchid-dental.co.uk
Our treatment coordinator will contact your patient promptly to arrange an appointment.
