Cedars Endo Endodontist Root Canal Treatment referral form

Referral Form

1. This form is ideally to be completed in full by the referring dentist. The information provided is confidential as per our privacy policy.
2. You will be referring your patients to a Specialist Endodontic Practice, unlike most endodontists we do not work within a general practice setting, no general dentistry is carried out at Cedars Endo.
3. We will contact your patients within 24 hours on receipt of referral
4. At Cedars Endo we guarantee to discharge your patients back to your continuing care following completion of their prescribed treatment
5. Your patients will be informed of all costs and a written treatment plan will be provided following their consultation
6. When applicable all patients are informed of the importance of a cast cusp covered restoration prior to the start of treatment
7. With your consent we are happy to place the definitive core at completion of the endodontic treatment
8. You will receive detailed correspondence following consultation through to treatment completion explaining our findings as well as any treatment carried out.
9. Our fees guide:
Specialist Endodontic Consultation: From £150
Treatment Fees: £950.00 to £1250.00 depending on tooth type and complexity. A full written treatment plan will be provided following consultation.
Thank you for your referral and taking your time to complete this form. A copy of the completed form will be emailed to you for your reference.
Patient First Name: *
Patient Last Name *
Date of Birth *
Sex
Patient Email
Patients Mobile *
Patients Home Phone
Patients Work Phone
Patients Address *
Priority *
UrgentNon Urgent
Radiograph *
To be sent by postTo be emailed to reception @ cedarsendo.co.uk
Tooth/Teeth *
Radiograpgh Upload
Radiograph 2 Upload
Radiograph 3 Upload
Reason for Referral *
Medical History

Referral Dentist Details

Dentist First Name *
Dentist Last Name *
Dentist Signature *
Date *
If this form is being completed by a practice staff, please give details
Practice Name and Address *
Preferred Contact No *
Preferred Email *
Any Comments
Privacy Policy Before submitting this form please familairise with our privacy policy and submit only if you agree with them.
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