UK Sedation Dentists

Referrals

Referral form for New Park House Dental Centre / UKSedation

Please use this form for adult oral surgery referrals with or without IV Sedation.

We want to make the referral system as simple as possible, once you have submitted the form we will arrange a suitable time to see the patient.

Please don’t hesitate to contact us if you’ve got any questions.

Patient Details

Title

Title

First Name

Last Name

Date of birth

Patient address

Patient mobile phone number

Patient email address

Treatment requested

IV sedation required?

yes

Radiographs upload (can select multiple images)

Maximum upload size: 268.44MB

Referrer Details

Dentist Name

Referring practice

Contact name

Contact number

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