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Refer a Patient
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About
Menu Toggle
Our Team
News
Our Vision
Our Patients
Our Technology
Our Charity Partner
General Dentistry
Menu Toggle
Emergency Dentist
Dentures
Dental Bridges
Root Canal Treatment
Dental Fillings Liverpool
Healthy Gums
Sedation
Facial Aesthetics Liverpool
Cosmetic Dentistry
Menu Toggle
Teeth Whitening
Composite Bonding
Dental Implants
Orthodontics
Menu Toggle
Braces
Invisalign
Fees & Finance
Our Membership Plan
Referrals
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Refer a Friend Card
Refer a Patient
Contact
Book Now
Book a Referral
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Referring Dentist Details
Practice Name
*
Title
Title
Dr
Mr
Mrs
Miss
Ms
First Name
*
Last Name
*
Practice Address
*
Practice Postcode
*
Practice Phone Number
*
Email Address
*
Patient Details
First Name
*
Last Name
*
Address
Street Address
Address Line 2
County
Postcode
Home Phone Number
Mobile Number
Email Address
*
Date of birth
*
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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24
25
26
27
28
29
30
31
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
Year
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
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1965
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1963
1962
1961
1960
1959
1958
1957
1956
1955
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1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Further Information
Preferred Treatment
*
Preferred Treatment *
Bridges
CBCT
Cosmetic Dentistry
Dentures
Facial Aesthetics
General Dentistry
Hygienist Services
Implants
Oral Surgery
Root Canal Treatment
Sedation
Teeth Straightening
Veneers
Whitening
X-ray / CBCT Referral Details
Reason for referral and clinical justification for X-ray / CBCT scan
*
Upper Arch
*
No Scan
Full Arch
Sectional
Lower Arch
*
No Scan
Full Arch
Sectional
Four teeth of most importance for sectional view
*
What information do you want the dental CBCT examination to provide?
*
Patient to wear splint provided by dentist?
*
Yes
No
Splint Positioning
*
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 referrer/operator
*
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.
Clinical Details
Teeth to treat
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
Clinician Requested
*
Case history / Reason for referral
*
Radiograph Upload
Drop files here or
Select files
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Medical Details
Relevant medical history and current medication
*
Signature (Full Name)
*
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Date of referral
*