Referral – Curran Oral Surgery Clinic

Curran Surgery Web Referral Service

Scheduled appointment date, if already booked

Scheduled appointment time, if already booked

Patient Name*

First

Last

Date of Birth*

day

month

year

Health Number*

Address*

Street Address Street Address Line 2 City Postal / Zip Code Country

Tel/Mob Number*

Relevant Medicial History

Would you prefer this patient to be seen by a particular clinician? *

YES

If yes, which clinician?

RA SEDATION? *

YES

IV SEDATION? *Patients having I.V. sedation should fast for 2 hours prior to appointment and be accompanied by a responsible adult, who can take them home and look after them for approx. 24 hours following treatment. *

YES

Procedure

Teeth

Payment source *

NHS

Private

Referring Dentist Name*

First

Last

Referring Practice email*

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