Patient Details Title: Please selectMrMrsMissMsOther Name:* Address:* Postcode:* Date of Birth:* Telephone (Day): Telephone (Eve): Mobile: Email: Is this referral urgent? YesNo 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 appropriateOpinion only Relevant Medical HistoryRelevant Medical History*:Clinical Details Level of Pain: 012 Level of Swelling: 012 Vital: YesNoUnsure Previous RCT at this tooth: YesNo If Yes: SelfOther Treatment HistoryRecent restoration: YesNo Any further details:Relevant File AttachmentsPlease 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).