Patient Details Title: Please select Mr Mrs Miss Ms Other Name:* Address:* Postcode:* Date of Birth:* Telephone (Day): Telephone (Eve): Mobile: Email: Is this referral urgent? Yes No Tooth / teeth to be treated:* Referring Dentist Details Referring Practitioner:* Practice Name:* Address:* Postcode:* Telephone:* Email:* Referral Details Details*: Reason For Referral: Investigate and treat, if appropriate Opinion only Relevant Medical History Relevant Medical History*: Clinical Details Level of Pain: 0 1 2 Level of Swelling: 0 1 2 Vital: Yes No Unsure Previous RCT at this tooth: Yes No If Yes: Self Other Treatment History Recent restoration: Yes No Any further details: Relevant File Attachments Please include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF. Attach Radiograph: YES, I’d like to be informed of exclusive offers and other practice information *By clicking ‘submit’ you are consenting to us replying, and storing your details. (see our privacy policy).