Patient Referral – Alcester & Howard Dentist Specialists

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Patient's Referral

Patient details

First Name

Surname

Date of Birth

Email

Tel

Any medical history of note

Dentist details

Dental practice referring

Dental practitioner referring

Tel

Date of referral

Email

Which practice are you referring to?

Dental speciality
Select the specialities relevant to you

Dental Speciality

Implants Periodontics Endodontics Oral surgery Restorative Pediatrics Orthodontics Sedation

Teeth/quadrant/area in question

quadrant

Quadrant 1 8 7 6 5 4 3 2 1

quadrant

Quadrant 2 1 2 3 4 5 6 7 1

quadrant

Quadrant 3 8 7 6 5 4 3 2 1

quadrant

Quadrant 4 1 2 3 4 5 6 7 1

quadrant

X-rays included X-rays to be returned Digital X-rays sent to the practice's email address Urgent Attach X-rays as image file

Attach X-rays as image file

Reason for referral

I confirm that I have the patient's permission to share their details with Alcester & Howard Dental Specialist

Have you got a dental emergency?

Dental Implants

Teeth Whitening

Hygiene

Anti Wrinkle Injections

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Opening Hours

Mon - Wed: 8.45AM - 5.30PM
Thu - Fri: 8.45AM - 7.00PM
Sat. 8:45AM - 5.30PM
Emergency appointments available Appointments outside normal opening hours may be available by arrangement

Contact

All Saints Centre, 2D Vicarage Rd, King's Heath, Birmingham B14 7RA
0121 444 8786
reception@ahdental.co.uk

Alcester & Howard Dental Specialists
are a part of All Saints Dental Clinic Group – Designed by Adseen

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