Patient details

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    Select the type of referral

    Treatment required (please tick all that apply)

    EndodonticsOrthodonticsImplantsIV Sedation
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    Referral for?

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    Which clinician are you referring to?

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    Has the patient been referred to us before?

    YesNo

    Referral Details

    Attachments:

    Has the patient been given an indication of our fees?

    YesNo

    Is the required treatment urgent?

    YesNo