Tower Hamlets PCT Specialist Endodontic Service Referrals to Waterside Dental Health

Thank you for your referral
1) Read the referral protocols. Click here. (PDF opens in new window)
2) Complete the online form (below). This is the preferred method
3) At the end you will be asked to confirm the data on the form before it is finally sent
4) If you wish to print a form and send it by mail, download it by clicking here
5) If at any time you wish to stop filling the online form, scroll down to the bottom to cancel

Specialist Endodontic Service Referral Form

* - required


	Patient's details

*Patient's
Surname/Family name:

*Patient's Forename:

*Date of Birth
(dd/mm/yyyy):

*Address Line 1.

Please confirm current address with patient

Address Line 2:

Address Line 3:

*Postcode:

Patient's preferred
phone number:

Patient's
alternative phone
number:

Patient's Email
Address:

Dental practice name
and address AND the
GP's name and
address IF patient
resides outside
postcode areas
E1,E2,E3 or E14:

(chars left: 1000)


	Reason for referral

*Main reason for referral. Give details in History Box below:

*Brief medical and dental history and endodontic procedure requested.
Please include current medication and or medical therapy:

(chars left: 2000)


	Referring Dental Practitioner

*Referring Dentist's
Name:

*Phone:

*I confirm the following:

Recent radiographs will be uploaded below
Recent radiographs will be emailed
Recent radiographs will be posted

Note: Referral requests will not be processed before the radiographs are received

Upload 1:

Max 4Mb

Upload 2:

Max 4Mb

Upload 3:

Max 4Mb

*NHS charge collected:

DO NOT enter a £ sign or the form won't send. Thanks.

*Referral Date:

/ /

Form Generated by FORMgen