Hornchurch
229 Hornchurch Road, Hornchurch Essex RM12 4TP
t: 01708 707050
Leigh-on-Sea
1809 London Road, Leigh-on-Sea Essex SS9 2ST
t: 01702 553535

Referral Form

Referral Form

Patient Details
Referring Dentist's Details
Referral Details

Please add as much relevent clinical history information as possible, If referral related to a CT scan please add justification for scan.

Please add ad much relevant medical history as possible, in particular significant conditions, allergies or medications.

Supporting Files

Please tick the supporting material you will be posting us or attaching. If you have any relevent radiographs, please so send them preferably by email or by attaching to this referral. Enclosures can also be emailed to [email protected] under separate cover. If emailing or uploading attachments ( e.g. X-rays) , for security please omit patients name but add the following details in the subject line: Patients initials, Patients Date of Birth, Referring Dentists Name.

Please include any relevant file attachment such as radiographs, clinical notes or photographs.

Allowed extensions .jpg, .jpeg, .png, .gif, .doc, .docx, .pdf. Maximum size 2MB (each).

Book Appointment
For any enquries or quotes
call us on

 
01702 553535
 
Leigh-on-Sea
 
Or
 
01708 707050
 
Hornchurch