01653 693809
reception@redhousedentists.co.uk
Referral form
Should you wish to discuss a case prior to referral, or just get some advice, please do not hesitate to contact us on 01653 693809.
For patients where urgent management is required, please phone us ahead of sending the referral.
Dentist Details
Referring Dentist
Address 1
Address 2
Town
Postcode
Telephone
Email
Patient Details
Patient Name
Date of Birth
Address 1
Address 2
Town
Postcode
Telephone
Mobile
Email
Please select type of referral:
Endodontic
Oral Surgery
Reason for referral
Apical periodontitis
Irreversible pulpitis
Fractured post/file
Perforation
Sclerosed canal
Root resorption
Failed endo
Tooth/Teeth of concern:
Please add relevant medical history:
Please add any other information that you think may be helpful:
Please attach any relevant radiographs:
Add More Files
I certify that the information provided on this referral form is accurate to the best of my knowledge, and that the patient has consented to onward referral for the provision of endodontic treatment.
We will contact the patient directly to arrange an appointment. Patients will be cared for only as requested and will be returned once treatment is completed. Upon completion of treatment a clinical report will be provided for the patient's records.
Due to capacity, we regret the Dr Lucy Frost is presently unable to take Oral Surgery referrals at the present time. We will keep the website updated and let you know as soon as Dr Frost has capacity to take further referrals.
01653 693809
reception@redhousedentists.co.uk