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Home
About
Treatments
Menu Toggle
General Dentistry
Menu Toggle
Regular Care
Hygiene
Crowns
Bridges
Dentures
Cosmetic Dentistry
Menu Toggle
Improve Your Smile
Clear Aligners
Composite Bonding
Teeth Whitening
Veneers
Specialised Services
Menu Toggle
Dental Implants
Oral Surgery
Sedation
Insights
Refer
Contact
Book Online
Referrals
Dental FX welcomes referrals from all dental practitioners.
Company
This field is for validation purposes and should be left unchanged.
Patient Details
Patient Name
(Required)
First
Last
Patient Date of birth
(Required)
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Day
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Patient Address
(Required)
Address Line 1
Address Line 2
City
County
Postcode
Patient Email
(Required)
Patient Contact Phone Number
(Required)
Type of referral
I am referring for
(Required)
Implant Case
Oral Surgery
Restorative
Cosmetic / Advanced Restorative
Root Canal Treatment
Specialist Periodontal Care
CT Scan
OPG
This case
Is Urgent
Requires IV Sedation
Endodontic Referral
(Required)
Root Canal Only
Root Canal and Restoration
Implant Referral
(Required)
Opinion Only
Bone Grafting / Sinus Elevation / Soft Tissue Correction
Surgical Placement / Uncovering
Full Case
Preferred Clnician
(Required)
Dr James Millar
Dr Catriona Easton
No preference
Preferred Implant System
Oral Surgery
(Required)
Retained Roots
Apicectomy
Wisdom Teeth
Other
Charting
Teeth to treat
(Required)
UR8
UR7
UR6
UR5
UR4
UR3
UR2
UR1
UL1
UL2
UL3
UL4
UL5
UL6
UL7
UL8
LR8
LR7
LR6
LR5
LR4
LR3
LR2
LR1
LL1
LL2
LL3
LL4
LL5
LL6
LL7
LL8
Radiograph or Image
Drop files here or
Select files
Accepted file types: jpg, gif, tif, png, jpeg, Max. file size: 128 MB, Max. files: 3.
CBCT Referral Details
Reason for referral and clinical justification for CBCT scan
(Required)
If sectional view requested please state 4 teeth of most importance
(Required)
Define the anatomical area that the scan should cover
(Required)
What information do you want the dental CBCT examination to provide?
(Required)
Patient to wear stent provided by dentist ?
(Required)
Yes
No
Positioning of splint
(Required)
I confirm the patient is competent in positioning splint
Due to the many different types of radiographic stents, it is essential that you ensure that your patient is competent in positioning it to your specifications.
IRMER Compliance
IRMER referrer/operator
(Required)
I am the IRMER referrer/operator. I am adequately trained to report on my patient’s scan. 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. We advise that all CT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology.
Further Details
Patient Complaint / Reason for Referral
(Required)
Relevant Medical History
Dentist Details
Dentist Name
(Required)
First
Last
Dentist Email
(Required)
GDC Number
(Required)
Practice Details
(Required)
