Book Book an appointment

New: 01297 442907

Existing: 01297 442907

Home
The practice & team
Treatments
Plans & fees
Articles
Referrals
Book an appointment

Referrals
Referral Form

Make a referral

To refer a patient to Lyme Bay Dental & Implant Clinic, simply complete and submit the below referral form.

Please include all relevant clinical information regarding this case, and remember to attached any x-rays if relevant.

After reviewing, we will contact the patient to introduce ourselves and book them in. We will also keep you fully updated on progress throughout.

Patient details (step 1)

click to open click to close

First name *

Last name *

Address 1 *

Address 2 *

Postcode *

Date of birth *

Contact number *

Email *

Please check that the following fields have been filled out correctly:

Referring Dentist Details (step 2)

click to open click to close

First name *

Last name *

Phone number *

Practice name *

Practice address line 1 *

Practice address line 2

Practice city *

Practice county *

Practice postcode *

Email address *

Please check that the following fields have been filled out correctly:

Referral Details (step 3)

click to open click to close

Enter the name of the relevant clinician to refer your patient to (if known)

Treatment required *

Reason for referral/treatment required. Please detail relevant dental history and preferred clinician if applicable

General assessment of dental health

Oral hygiene *

Poor Fair Good Other

Teeth of poor prognosis *

Relevant medical history *

Additional files
- Please note that only the following file types are supported: jpeg, jpg, png, gif, pdf, doc, docx, xls, xlsx, rtf, ppt, odt.

Other records sent via post

Radiographs Study models Diagnostic wax up None Other

Final restoration to be placed by:

By Lyme Bay Dental & Implant Clinic

Any comments

Confirmation

I confirm I have the requisite authority to share the patient's information in connection with this referral

Please check that the following fields have been filled out correctly:

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Lyme Bay Dental & Implant Clinic and Portman Dental Care are trading names of Portman Healthcare Ltd, registered in England and Wales: 06740579. Registered office: Rosehill, New Barn Lane, Cheltenham, Glos, GL52 3LZ. Portman Healthcare Ltd is authorised and regulated by the Financial Conduct Authority as a credit broker under registration number 700090. Credit is subject to status and affordability, and is provided by Novuna Personal Finance a trading style of Mitsubishi HC Capital UK PLC. Terms & Conditions Apply. Portman Healthcare Limited is the controller of your data and registered with the Information Commissioners Office under registration number Z1929449

*This offer is valid for new and existing patients who attend the implant open day on 7 February 2025 at Lyme Bay Dental & Implant Clinic for a free consultation and a free CT scan and treatment plan. Consultations must be booked in advance and are subject to availability. Offer is open to over 198s only and patients must be dentally fit proceed with courses of treatment. Whether a patient is deemed dentally fit for treatment will be at the clinician’s absolute discretion. Additional treatment required to make a patient dentally fit and suitable for treatment will be charged at an additional cost. Lyme Bay Dental & Implant Clinic reserves the right to change or withdraw this offer at any time. This offer is non-exchangeable, non=transferrable and is not redeemable for cash or other treatments.

Copyright © 2024 Portman Healthcare. All rights reserved.

Last updated 04/11/2024 at 11:49

About Portman
Complaints
Careers
Get in touch
Privacy Policy
Legal
Terms and Conditions