Crossbank Dental Care Referral Form

Crossbank Dental Care Referral Form
Patient details
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area codePhone Number
Email
example@example.com
Type of referral

Please tick as appropriate
Implant

Opinion onlyFull case referralGrafting (bone block/sinus/soft tissue)Surgical referral (implant placement and uncovering)
Endodontic

Opinion onlyRoot fillingPre-root fillingPost removal
Cosmetic/complex

Opinion onlyCrown/bridgeDenturesTooth wearWhitening - full smileWhitening - internalInvisalign
Oral surgery

Impacted teethRetained rootsApicoectomy
Hygiene

Routine scale and polishFull mouth disinfectionCustomised hygiene instruction
Radiographs

Cone Beam CT ScanOPG
For you to be able to refer for a Cone Beam CT Scan you will need a Service Level Agreement with Crossbank Dental Care, this can be arranged by contacting our Treatment Coordination Team at tco@crossbankdental.com or 01539 720820.

The below fields MUST be completed if you have selected a referral for radiograph.
Justification for radiograph
Tooth notation (5cm x 5cm field of view)
Format required
Fee payer

Referring dentistPatient
Do you have a scan template to be fitted?

YesNo
I confirm I will provide my own radiographic report unless I request otherwise, I understand that if I require a report this will incur an additional fee.
Reason for referral
Relevant medical history
Photo/X-rays upload

Cancelof
Dentist details
Name of referring dentist*

First NameLast Name
Dentist address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dentist phone number*

Area CodePhone Number
Dentist email address*
example@example.com
Should be Empty:

Crossbank Dental Care Referral Form

Patient details

Type of referral

Dentist details