Referral form | Stradbrook Dental Clinic, Tonbridge, Kent

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Existing: 01732 770666

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Referrals
Referral Form

Make a referral

To refer a patient to Stradbrook Dental & Implant Clinic, simply complete and submit the below referral form.

Please include all relevant clinical information regarding this case, and remember to attached any x-rays if relevant.

After reviewing, we will contact the patient to introduce ourselves and book them in. We will also keep you fully updated on progress throughout.

For CBCT scan referrals, please contact Stradbrook Dental & Implant Clinic on 01732 771402 or [email protected]

Patient details (step 1)

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First name *

Last name *

Address 1 *

Address 2 *

Postcode *

Date of birth *

Contact number *

Email *

Please check that the following fields have been filled out correctly:

Referring Dentist Details (step 2)

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First name *

Last name *

Phone number *

Practice name *

Practice address line 1 *

Practice address line 2

Practice city *

Practice county *

Practice postcode *

Email address *

Please check that the following fields have been filled out correctly:

Referral Details (step 3)

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Enter the name of the relevant clinician to refer your patient to (if known)

Treatment required *

Reason for referral/treatment required. Please detail relevant dental history and preferred clinician if applicable

General assessment of dental health

Oral hygiene *

Poor Fair Good Other

Teeth of poor prognosis *

Relevant medical history *

Additional files
- Please note that only the following file types are supported: jpeg, jpg, png, gif, pdf, doc, docx, xls, xlsx, rtf, ppt, odt.

Other records sent via post

Radiographs Study models Diagnostic wax up None Other

Final restoration to be placed by:

The Referring Dentist By Stradbrook Dental & Implant Clinic

Any comments

Confirmation

I confirm I have the requisite authority to share the patient's information in connection with this referral

Please check that the following fields have been filled out correctly:

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Stradbrook Dental & Implant Clinic and Portman Dental Care are trading names of Portman Healthcare Ltd, registered in England and Wales: 06740579. Registered office: Rosehill, New Barn Lane, Cheltenham, Glos, GL52 3LZ. Portman Healthcare Ltd is authorised and regulated by the Financial Conduct Authority as a credit broker under registration number 700090. Credit is subject to status and affordability, and is provided by Novuna Personal Finance a trading style of Mitsubishi HC Capital UK PLC. Terms & Conditions Apply. Portman Healthcare Limited is the controller of your data and registered with the Information Commissioners Office under registration number Z1929449

*Whitening treatment can only be conducted on patients who are dentally fit. A dental examination, charged additionally, is required prior to treatment commencing to assess suitability for treatment. For existing patients, this examination can be included within your usual dental exam at no additional fee, if you make this known to your dentist. If additional dental work is required prior to treatment commencing, this will be charged in addition to the whitening treatment. This offer is not open to any person under 18 years old of age at time of treatment. This discount is not available with any other offer or promotion.

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Last updated 11/12/2024 at 8:49

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