Apex Endodontics – Dental Focus Secure Forms

Patient Details

Patient Title

(Mr/Mrs etc)

Patient First Name*

Patient Surname*

Patient's Address*

Patient's Email

Patient's Phone Number*

Patient's Date of Birth*

Referring Dentist's Details

Dentist's Name*

Practice Name*

Practice Address*

Referring Dentist's Email Address*

Dentist's Phone Number*

Referral Details

Medical History*

Relevant history*

Teeth/Quadrant/Area in Question

Upper Jaw Right Quadrant

Upper Jaw Left Quadrant

Lower Jaw Right Quadrant

Lower Jaw Left Quadrant

Additional Information

Treatment Required*

Other Treatment - Please Specify

Type of restoration you would like us to place*

Final Restoration (composite/post if appropriate)

Temporise and return for restoration (GIC)

Post space only

If the tooth is deemed unrestorable are you happy for us to extract the tooth*

Yes

No - I will make my own arrangement for extraction

CBCT Scan

The CBCT image will be reported on by the referring dentist as per your service level agreement - we can arrange for an outside source to report on findings at an additional cost. Important information: it is essential that you complete all sections of this form in full. All incomplete forms will be returned to the referring dental practice, which may result in a delay in your patients’ treatment. The referring practice will be responsible for ensuring the clinical evaluation takes place and is properly recorded.

Reason for Referral*

Define the anatomical area that the scan should cover*

What information do you want the dental CBCT examination to provide*

Attach files to your referral

Please include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 512 MB.

Signature