Horbury Dental Referral Form
Referring to:




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Referring Dentist's Details
Practice Name
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Practice Address
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Post Code
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Phone Numbers
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If Implant Patient - would you like to be present to view?
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Would you like your Patients treatment to be completed at HDC?
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Please write your full name below including your GDC number. This will act as an electronic legally binding signature
Referring Dentists Name
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Referring Dentists email(*)
Please type in the referring dentist's email address
GDC Number
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Date
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Patient Details
Title
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Full Name
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Address
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Post Code
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Patients Phone Numbers
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Patients Date of Birth(*)
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Please enter the patients date of birth
General Medical Practitioner Details
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Medical History
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Dental History
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Sedation Required
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Smoker
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Reason for Referral
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Other Notes/Comments
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If you'd like to add any supporting attachments / images / digital x-rays to support you referral please email them to Jill.Hatfield@horburydentalcare.co.uk. Thank you.
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