Studio I 51 St Pauls Square Birmingham B3 1QS
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Online Referral

Alternatively, you can download and complete our referral form using the links below.

General Referral Form

Referring Dentist Details
Name:
*
Practice:
 
Address:
 
Post Code:
 
Referral Date:
 
Telephone:
 
Email:
*
Patient Details
Name:
*
Address:
 
Post Code:
 
DOB:
 
Telephone (Home):
 
Telephone (Mobile):
 
Email:
*
Relevant Medical History
 *
Type of Referral
Regular Patient to Your Practice New Patient to Your Practice
Radiographs (Please Upload) Study Models (Please Upload)
Photographs (Please Upload)  
   
Reason For Referral
Implant Consultation Periodontology Consultation
Sedation / Nervous Patient TMD / Facial Pain
Facial Aesthetics Oral Surgery
Orthodontics  
Verification
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I consent to my personal data being collected and stored for the purpose of marketing communications.

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Endodontic Referral Form

Referring Dentist Details
Name:
*
Practice:
 
Address:
 
Post Code:
 
Referral Date:
 
Telephone:
 
Email:
*
Patient Details
Name:
*
Address:
 
Post Code:
 
DOB:
 
Telephone (Home):
 
Telephone (Mobile):
 
Email:
*
Relevant Medical History
 *
Type of Referral
Regular Patient to Your Practice New Patient to Your Practice
Reason For Referral
Consultation Only Initial Root Treatment
Re-Root Treatment Post Removal
Trauma Perforation / Root Resorption Treatment
Instrument Removal Post Core Build-Up
Endodontic Surgery  
Verification
I consent to my personal data being collected and stored as per the Privacy Policy* .
I consent to my personal data being collected and stored for the purpose of marketing communications.

To prevent spam using our form, please enter the characters as shown in the image opposite.

Verify *   
Send

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CT Imaging Referral Form

Referring Dentist Details
Name:
*
Practice:
 
Address:
 
Post Code:
 
Referral Date:
 
Telephone:
 
Email:
*
Patient Details
Name:
*
Address:
 
Post Code:
 
DOB:
 
Telephone (Home):
 
Telephone (Mobile):
 
Email:
*
Relevant Medical History
 *
Type Of View Required
 2-D  3-D
Digital Panoral Upper Jaw
Digital Lateral Cephalometric Lower Jaw
  Sinus
  Zygoma
  Left TMJ
  Right TMJ
  Small Volume (Please Specify Area Or Tooth)
Verification
I consent to my personal data being collected and stored as per the Privacy Policy* .
I consent to my personal data being collected and stored for the purpose of marketing communications.

To prevent spam using our form, please enter the characters as shown in the image opposite.

Verify *   
Send

Dentist Referral Birmingham - St Paul Square Referral Centre

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Dentist in Birmingham
Last Update: 18-Apr-2024