Referring Practitioner
Patient Details
Tooth/Teeth to be treated (tick as appropriate)

Upper Left

Upper Right

Lower Left

Lower Right

Treatment/s Required
Additional Information

Sedation required?

Is the patient a smoker?

Supporting Documents

All patients who have been referred to Portlethen Dental Care will be returned to you on completion of treatment. You will be kept fully informed throughout your patient’s progress, both at the consultation stage and following treatment. If your patient has been referred for consultation advice you will be contacted as soon as possible regarding this advice.

If you have any concerns or questions or would like to discuss any aspect of your patient’s care with the specialist please do not hesitate to contact the practice.