Patient
   
Personal Details:
Name
Surname
Date of birth
 
 
Patients Address Details
Address
Address
Town
County
Postcode
   
Contact Details:
Home Phone
Mobile Phone
Email
Dentist
   
Referring Dentist:
Name
Surname
Telephone
Email
   
Dentist Address Details
Address
Address
Town
County
Postcode
   
Options:
Practice
Treatment
   
Referral Reason
RM History
DPT radiograph taken within last 2 years? If yes, please forward and we will copy and return it.


Please note for NHS referrals for the Cardiff practice, please go to http://www.cardiffandvaleuhb.wales.nhs.uk/document/209980, download the Orthodontic Referral Form, then send us the completed form via email (pontprennau-rec@idhgroup.co.uk) or post to: Beck Court, Cardiff Gate Business Park, Pontprennau, Cardiff, CF23 8RP.