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Dentist Referral Form

If you are a dental professional you can use the form below to refer to us for sedation dentistry, dental implants, wisdom tooth removal, or any other dental treatment. We look forward to hearing from you.

Purpose of referral IV Sedation Other

* required fields

Sedation checklist - please tick to confirm that you have checked the following:

Patient is over the age of 18:*
YesNo

Patient has a BMI > 18 and < 35:*
YesNo

Have you discussed the nature of the referral with the patient?*
YesNo

Justification for sedation - please tick all that apply:

Specify an option*

Anxiety
Lack of co-operation
Needle phobic
Prolonged / unpleasant treatment
Increased gag reflex
Other (please state)

Practice Details

* required fields

Practice name:
*

Dentist name:
*

Email address:

List number:
*

Practice address:
*

Patient Details

* required fields

Patient name:
*

Patient email address:

Patient phone:
*

Patient DOB:
*

Patient address:
*

Medical Details

* required fields

Main reason for referral:
*

Relevant medical details:
*

Further clinical details:

Attach X-ray (or other relevant) files

Upload your file:

Upload your file:

Upload your file:

Stewartfield Dental Care

Unit 1, 5 Macneish Way, East Kilbride, G74 4TT

01355 458 118

About us

Simply fill out the form above and we'll contact the patient to arrange a convenient appointment

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