Dentist Referral

Use the form below to refer for Dental Implants, CBCT Scan, Minor Oral Surgery & IV Sedation

Referral Reason - Step 1 of 5

Select Referral Reason:

OPG Radiograph
CBCT Scan
IV Sedation
Dental Implantology
Wisdom Tooth Removal
Difficult Tooth Extraction
Full Mouth Rehabilitation

IV Sedation Referral Guidelines

Please ensure your patient is asware of the following:

1. An initial assessment appointment will be arrange to find out if they are suitable for IV Sedation.
2. A deposit of £50 will be taken from all patients prior to booking the initial consultation.
3. Once the treatment plan is formulated, the full payment is taken prior to booking the IV Sedation & treatment appointment.
4. The escort is not required to attend at the first initial assessment, but are welcome to attend.

OPG Referral Guidelines

Please ensure your patient is aware of the following:

1. The fee for an OPG (Orthopantomogram) radiograph is £65.
2. A deposit of £25 will be taken prior to booking the appointment.
3. The remaining balance is payable at the time of the appointment.
4. All patients must be referred by their dentist or healthcare professional. Please ensure referral details are provided in advance.
5. The radiograph will be sent securely to the referring practitioner after the appointment.
6. Patients will not receive a diagnostic report directly; interpretation is the responsibility of the referring clinician.
7. Please advise patients to bring any relevant previous radiographs or documentation if applicable.

CBCT Scan Referral Guidelines

Please ensure your patient is aware of the following:

1. The fee for a CBCT scan is £125 for a single arch and £200 for a full mouth scan.
2. A deposit of £50 will be taken prior to booking the appointment.
3. The remaining balance is payable at the time of the appointment.
4. All patients must be referred by their dentist or healthcare professional. Please ensure referral details and the specific area of interest are provided in advance.
5. The scan images will be sent securely to the referring practitioner after the appointment.
6. Patients will not receive a diagnostic report directly; interpretation is the responsibility of the referring clinician.
7. Please advise patients to bring any relevant previous radiographs or documentation if applicable.

Wisdom Tooth Removal Referral Guidelines

Please ensure your patient is asware of the following:

1. An initial assessment appointment will be arrange to find out if they are suitable for Surgical Wisdom Tooth Extraction
2. A deposit of £50 will be taken from all patient prior to booking the initial consultation.
3. Once the treatment plan is formulated, the full payment is taken prior to booking the wisdom tooth extraction appointment.
4. If a periapical radiograph has been attempted, please attach to this referral (at the final step).
5. If an OPG is required, please inform the patient that there be additional cost.

Dentist's Name *

GDC Number *

Dentist's Phone Number *

Dentist Email *

Confirm Email

Practice Name *

Practice Address *

Practice Postcode *

Confirmation of IRMER Referrer Training *

I have undertaken training required to satisfy the minimum criteria as an IRMER Referrer / Conebeam CT which is covered on pages 49-53 of the Guidance of Safe Use of Dental Cone Beam CT (Computed Tomography) Equipment prepared by the HPA Working Party on Dental Cone Beam CT Equipment. (Click to read guidance notes)

You must have undertaken training required to satisfy the minimum criteria as an IRMER Referrer / Conebeam CT which is covered on pages 49-53 of the Guidance of Safe Use of Dental Cone Beam CT (Computed Tomography) Equipment prepared by the HPA Working Party on Dental Cone Beam CT Equipment to request a CBCT image. YOU WILL NOT BE ABLE TO CONTINUE WITH THIS REFERRAL

Patient's Name *

Patient's Date of Birth *

Patient's Phone Number *

Patient Email

Patient's Address *

Patient's Postcode *

Patient Payment Options *

Private Fees Information

Please ensure your patient is asware of the following:

1. An initial assessment cost is £50.
2. All treatment cost is paid prior to booking the treatment appointment.
3. Full private treatment item cost is available: Click Here

Private referral confirmation *

I can confirm that the patient is being referred to Ilford Dental Care as a private patient and the above information has been or will be passed on to the patient.

Select Arch

Maxilla
Mandible
Full Arch

Anatomy to Include

Sinus
Zygoma
TMJ

Delivery Option

Patient (USB Drive & Email)
Referring Dentist (Email)
Both

In accordance with IR(ME)R 2000 a clinical justification must be provided for each dental CBCT scan and the scan must be
clinically evaluated by someone trained in the analysis of dental CBCT scans.

Reason for referral & justification for scan *

Special Instructions to IRMER operator involved in scan acquisition *

Proposed Treatment Plan *

File Upload - Attach any treatment plan, specialist letters and radiographs

Click or drag files to this area to upload. You can upload up to 10 files.

Consent Confirmation *

I consent to my personal data being collected and stored as per the Privacy Policy.

Custom Captcha *

Name

SELECT REFERRAL OPTION (Hold CTL to select multiple options)

Referral Option

REFERRING DENTIST DETAILS

Dentist First Name

Dentist Surname

GDC Number

Dentist Phone Number

Dentist Email

Practice Name

Practice Address

Practice Postcode

PATIENT DETAILS

Patient's First Name

Patient's Surname

Patient's Date of Birth

Patient's Phone Number

Patient's Address

Patient's Postcode

Proposed Treatment Plan

File Upload

(Upload any radiographs and / or photographs related to the proposed treatment plan.)

Consent

I consent to my personal data being collected and stored as per the Privacy Policy.

Consent2

I have informed the patient that this is a private referral only.

Dentist Referral

IV Sedation Referral Guidelines

OPG Referral Guidelines

CBCT Scan Referral Guidelines

Wisdom Tooth Removal Referral Guidelines

Private Fees Information

How to Find Us

Ilford Dental Care

Address

Phone

Work Time

Contact Us