MAKE A REFERRAL TO EGT

PATIENT DETAILS Date of Referral: * Patient Name: * Date of Birth: * Address: * Postcode: * Phone/Mobile: * Email: *

REFERRAL TYPE (please tick)

Implant Dentistry
Restorative Dentistry
Periodontics

Referral Details: * Medical History: *

REFERRING PRACTITIONER DETAILS Name: * Address: * Telephone Number: * Referrer Email: * Please upload any radiographs or supporting files here (Accepted file types PDF, JPG, PNG) I consent to my submitted data being collected and stored (Please tick) This referred patient has consented to their submitted data being collected and stored (Please tick)

DISCLAIMER

Edinburgh Gums and Teeth will not pass on the stored personal data to third parties or use the data for marketing purposes. You may request a ‘Withdrawal of Consent Procedure’ by contacting us via email: smile@edinburghgumsandteeth.co.uk

EDINBURGH GUMS & TEETH

37 Frederick Street, Edinburgh EH2 1EP
Tel: 0131 202 7980

REFERRAL

MAKE A REFERRAL TO EGT

DISCLAIMER