MrMsMrsMissDr

Home address

Referring colleague details and contact details

Name of referring clinican
MrMsMrsMissDr

Profession of referring clinican
Dental surgeonDental hygienist / therapistGeneral medical practitioner

Address of referring clinician

Reasons for referral

Emergency visits - does your patient require urgent attention for any of the following?

InvisalignEndodonticsCBCT ScansWhitening

Please let us know what you would like us to see your patient for?

GDPR and consent

Please read carefully and indicate consent where appropriate.

It is normally more convenient during long treatments to co-ordinate hygienist appointments in-house. However, at the end of treatment, we will refer the patient back to your hygienist with notes on recommended home care unless you would prefer for us to look after the patient's future hygiene. It is normally a condition of our 5 year guarantee that the patient sees the hygienist at prescribed intervals during the year.

All patients will be returned to your care at the end of treatment with a closing letter and we will actively decline to provide all non-essential treatment outside the remit of your referral without consulting you first.

With your permission we would like to recall the patient at yearly intervals for a review and follow up and audit of our work.

Consent for your referred patient's care at Chapel Dental - please tick as required:

I consent to Chapel Dental contacting the above patient for the purpose of consultation and treatment as detailed aboveI consent to Chapel Dental carrying out all appropriate treatment as agreed with my patientI consent to Chapel Dental carrying out hygiene during treatmentI would prefer to continue hygiene care on my patient after treatment has been completedI would prefer hygiene visits to continue at Chapel Dental after completion of treatmentI consent to Chapel Dental continuing to recall my patient for review appointments as advised after end of treatment

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