Patient Information

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Please enter your first name
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Please enter your date of birth
Please enter your age
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Referring GDP Information

Please enter the referrers name
Please enter the referrers contact number
Please enter the referrers email address
Please enter the practice name & address
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Please advise if treatment been attempted pre-referral
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Please select the reason for referral
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Please advise whether the patient has any previous experience with sedation
Please advise if there any relevant radiographs to accompany the referral
Please advise if there are any known barriers to mobility
Please advise if the patient been informed that an assessment will be required and there is an associated fee.

* A fee of £100 will be applicable for the initial consultation that will be required to secure an appointment, this fee is non-refundable but will be deducted off the overall cost should the patient decide to proceed.

Please enter the referrer name
Please enter todays date