Referral Form for Surgical Extractions at Brighton Dental Clinic

Surgical Extractions Referral Form

Patient Details (All fields with an * are required)

Mr Mrs Miss Ms Other

Name *

Address

Postcode *

Is this referral urgent? * Yes No

Date of Birth *

Telephone (Day)

Telephone (Evening)

Mobile *

Email *

Treatment Required (All fields with an * are required)

Tooth or teeth to be extracted *

Relevant Clinical Information

Medical History

Attach Radiograph

Correspondence Details (All fields with an * are required)

Referring Dentist Name *

Correspondence Email *

Correspondence Telephone

Please send a pdf copy of the referral details to the correspondence email address

St James's Mansions, Old Steine, Brighton, BN1 1EN

01273 570 700

smile@brightondentalclinic.co.uk

Brighton Dental Clinic

We provide the best dental care and value for money over a wide range of treatment options, all carried out in an empathetic and relaxing environment.

Invisalign^® Offer

Dental Surgeons

Anaesthetist

Dental Hygienist

Nurses - Receptionists

General Dentistry

Periodontics & Preventive Dentistry

Orthodontics

Endodontics

Missing Teeth

Facial Aesthetics

Aesthetic Dentistry

Sedation

Extractions Referral

Surgical Extractions Referral Form

Brighton Dental Clinic

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