Make a referral

To refer a patient to South Down Clinic, simply complete and submit the referral form below.

Please include all relevant clinical information regarding this case, and remember to attach any x-rays if relevant.

After reviewing, we will contact the patient to introduce ourselves and arrange an appointment. We will also keep you fully updated on progress throughout.

Referral Form

Endodontics

Has the tooth been assessed as restorable?

Yes

Please share details of signs and symptoms related to the specific tooth/teeth

Do you want South Down Dental & Implant Clinic to restore the tooth after treatment?

Yes

Which of the following does the patient require:

Referrals without appropriate radiographs may not be accepted.

Maximum file size: 67.11MB

Implantology

How many teeth are missing in the upper jaw?

How many teeth are missing in the lower jaw?

Does the patient have dentures

Yes

Please select the following:

Full denture

Partial denture

Does the patient have any bridges in place?

Yes

Has the patient been informed about the financial implications of dental implants?

Yes

How much are you willing to invest into your teeth (£)?

8750

TMJ / Facial Pain

Select the following signs and symptoms that the patient is experiencing:

Clicking / pain in joint(s)

Yes

Reduced occlusal function

Yes

Stress / anxiety present?

Yes

Clenching / grinding / other habits, please specify

Other relevant information

Referring dentist details

First Name *

Surname *

Practice address line 1 *

Practice address line 2

Practice city *

Practice country *

Practice postcode *

Practice phone number *

Practice email *

Patient details

Title

First name *

Surname *

Email *

Contact number (mobile) *

Contact number (home)

DOB *

Address *

postcode *

Confirmation

Checkboxes *

I confirm I have the patients consent to share this information

If you are human, leave this field blank.

Make a referral

To refer a patient to South Down Clinic, simply complete and submit the referral form below.

Scroll to a section

Choose a treatment(s)

IV Sedation

IV Sedation

Endodontics

Endodontics

CT Scanning

CT Scan

Implantology

Implantology

TMJ / Facial Pain

TMJ / Facial Pain

Referring dentist details

Patient details

Medical History - Private and Confidental

Females Only

Females Only

General Assessment of Dental Health

General Assessment of Dental Health

Confirmation