REFERRAL FORM
IN HOUSE WHITENING
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Referring Dentist Name:
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Patient Name:
Referring Practice Address:
Patient Address:
Patient Date of Birth :
Patient Tel Number:
General medical practitioner details:
Date of referral:
History presenting complaint:
Treatment referred for: (please give long hand tooth notation eg upper left second molar)
Chart tooth for extraction - Upper Right
Chart tooth for extraction - Upper Left
Chart tooth for extraction - Lower Right
Chart tooth for extraction - Lower Right
IV Sedation with midazolam: (select yes or no)
Relevant medical history. Please tick as appropriate
Any other relevant medical history:
Medications list:
If referral is for sedation please provide Weight and Height:
Smoke: (select yes or no)
Alcohol units per week
Mobility support required? (select yes or no)
Relevant radiographs attached?
NB if referring a lower wisdom tooth, please provide an OPG. If you do not have access to an OPG machine, please state below and we can arrange this at the practice for a fee.
Do you need OPG (select yes or no)
Prices
If accepted for treatment, patients will be required to pay a deposit towards treatment to secure their appointments. If patients fail to attend, this deposit will be non-refundable.
Consultation fee £75
Intravenous sedation £325
Lower wisdom tooth extraction from £350
Surgical/complex extraction from £280
Simple anterior extraction from £180
Simple premolar/molar extraction from £225
Coronectomy from £350
Chestnut Smile Centre Ltd are offering a referral service for some oral surgery procedures. We are offering treatment provided by a dentist with a special interest in oral surgery.
For their first appointment, all patients will require a new patient consultation prior to undergoing their treatment.
Patients can be referred by dentists via the referral form below. Referrals will be triaged and we will notify you if your referral is accepted, declined, or if we require further information. We can offer OPGs if required.For any patients wishing to self-refer, please contact the practice using the contact details on the contact us section.
