Referral Form - Dental Health Club

periodontal referral centre including the STAR pathway

Focussed on both periodontal and peri-implant diseases, we aim to deepen understanding and refine treatment protocols, ensuring better patient outcomes. Our commitment is backed by continuous audits of patient outcomes, providing clear evidence of our services' effectiveness and high standards.

Patient Details

Mr/Mrs/Miss/Ms/Other

First Name

Surname

Date Of Birth

Address

Street Address Address Line 2 City Post Code

Email Address

Telephone Number

General Medical Practioner

Additional Referral Information:

Do you think this patient would benefit from specialist care?

Yes

Upload radiograph

Drop files here or

Max. file size: 12 MB.

Date of last radiographic examination

Referring Practioner

Name

Address

Postcode

Telephone Number