For cosmetic and restorative dentistry, dental implants and orthodontic referrals please complete the following form. Alternatively, you may download the referral form and send it by post or fax (020 7580 9343). Please call us to arrange an appointment for your patient on 020 7255 2559 or we can contact your patient directly if you prefer.

Referring Practitioner
Name *
Address

Postcode
Email *
Telephone *
Patient details
Title *
FirstName *
LastName *
DOB * dd/mm/yy
Address

Postcode
Email
Telephone *
Reason for Referral
Cosmetic dental
Implants only
Implants and final restoration
Orthodontics
Periodontics
Endodontics
Case description
Please: Investigate and treat
For opinion only
Chief Complaint:
Additional Details / Requests:

Skeletal Class:

Class 1
Class 2
Class 3

TMJ Symptoms:

Nil
Left
Right
Relevant Medical History:
Attachments (relevant photos or X-Rays)

Upload images

Browse and upload files upto 6 images (.jpg, .jpeg).
Images will be submitted after pressing "Send" button.
Please note: All photographs submitted to us will be kept strictly confidential and not shared with any third party.

We offer a referral service for both 2d and 3d radiography. Offering pre-bookable and a walk in service for patients needing Cephs, Opgs and CT scans.

Please complete the following form.Alternatively you may download the referral form, complete and give to your patient to bring with them.

Referring Practitioner
Name *
Address

Postcode
Email *
Telephone *
Patient details
Title *
FirstName *
LastName *
DOB * dd/mm/yy
Address

Postcode
Email
Telephone *
Relevant Medical History:
Possibility of pragnancy *

Examination Required
Panoramic:



Digital Cephalometric:


Cone Beam CT:
Region of Interest:






Case description
The clinical context for requesting a dental Panoramic / Cephalometric / Cone Beam CT
Relevant results of history, clinical examination and other imaging
What information do you want the Panoramic / Cephalometric / Cone Beam CT examination to provide?
Define the anatomical area that the scan(s) should cover
Software Options for Cone Beam CT Scans
CT Viewer
DICOM for SimPlant Pro DICOM for NobelGuide
GALAXIS
Delivery Options


Examination Required
Upper Right:
Upper Left:
Lower Right:
Lower Left:
 
Panoramic:



Digital Cephalometric:


Cone Beam CT:
Region of Interest:






Attachments (relevant photos or X-Rays)

Upload images

Browse and upload files upto 6 images (.jpg, .jpeg).
Images will be submitted after pressing "Send" button.
Please note: All photographs submitted to us will be kept strictly confidential and not shared with any third party.
IRMER 2000 Regulations: London Smile Clinic does not routinely report upon scans and radiographs. To comply with the IRMER 2000 regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. London Smile Clinic strongly recommends that all CT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology.

Referral charter

  • 1. Expertise

  • Our aim is to ensure that both the referred patient and you, the referring dentist, are delighted with the quality of our clinical expertise and the level of care and attention they receive from us.

  • 2. Trust

  • We will only carry out the treatment previously agreed with the referring dentist. We will always refer patients back for any other treatments, unless you request otherwise.

  • 3. Choice and consent

  • After the initial consultation, we will always provide the patient with a written treatment plan, a copy of which is always sent to the referring dentist. No treatment will be carried out without an estimate of fees given to the patient.

  • 4. Care

  • In the rare event where complications arise after the patient has been treated by us, we will always ensure that they receive the remedial care they require immediately.

  • 5. Support

  • Our aim is to ensure that as part of your extended dental team, we can add extra value to the overall patient experience you offer. We will support you and your patient every step of the way.