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Referral for Dental Treatment and/or Dermatology Consultation
Use this form for referral to Dental Sedation, Dental Root Canal, Dental Anti-Snoring Guard and Dermatology Consultation for advice and /or treatment. All information are kept confidential. Please complete all sections.
Section 1: Patient's Details
Prefix
First Name
*
Middle Name
Last Name
*
Date of Birth
*
Contact Number
*
Gender at Birth
*
Gender at Birth
Female
Male
Do not want to disclose
Email Address
*
Address
House No
*
Street Name
*
City
*
State/Province
*
Postcode
*
Country
*
Section 2: Referrer's Details
Prefix
*
First Name
*
Last Name
*
Professional Registration No.
*
Date of Referral
*
Practice Email Address
*
Practice Contact Number
*
All correspondence will be sent to this email
Practice Address
House No.
*
Street Name
*
City
*
State/Province
*
Postcode
*
Section 3: Case Details
Types of Referral
*
Types of Referral
Country
*
Case Details
*
Provide relevant medical history of the patient
*
File Upload
*
Click to choose a file or drag here
Size limit: 10 MB
Any other relevant x-rays/imaging. medical history, patient's care summary, letters, results or photographs. Photo of skin lesion, please have one up-close and one further away. 10MB limit. If exceed, please send to admin@dermdental.co.uk quoting patient's first and last initials and date of birth e.g John Smith 12 May 1965; JS12051965
Patient's Consent
*
Patient's Consent
I confirm that I have requisite authority to share the patient's information on connection with this referral
Signature
*
Referrer's Signature
Submit
