DENTIST REFERRAL – Orthodontist Dr Mo Dentist Dr Libi Edinburgh UK | Sunrise Dental Clinic Orthodontic & Paediatric Dentistry

Dental Services

Purpose of referral *

Paediatric Dentistry Referral
Orthodontic Referral
Joint Paediatric & Orthodontic Referral
Oral Surgery Referral
Cosmetic Dentistry
Prosthodontics & Occlusal Rehabilitation
Facial Pain & Jaw Joint Disorders Referral
General Dentistry Referral
Other Dental Service Referral

Which oral service do you require? *

Removal of wisdom teeth
Removal of teeth and roots
Exposure of unerupted teeth
Apicectomy or retrograde root filling
Cyst removal
Soft tissue surgery
Biopsy
Inhalation sedation
Intravenous sedation
Other services

Does the patient requires minor oral surgery treatment by the general dentist? *

Does the patient requires implant? *

Explain the types of minor oral surgery treatment required? *

Patient level of anxiety *

Anxious
Non-anxious

Is sedation required as part of a general dentistry referral? *

Yes
No
I will let your dentist decide

What type of sedation is required? *

Intravenous Sedation
Inhalation Sedation
I will let your dentist decide

Dentist details

Name of referring dentist *

Email of the referring dentist *

Name of clinic *

Clinic phone number *

Address of the clinic *

Please enter the full address, including the postcode

Patient Details

Title of the patient *

Name of the patient *

Gender *

Date of birth *

Patient's address *

Address Line 1

City

State / Province / Region

Postal Code

Please enter the full address, including the postcode

Phone number *

Email address *

Current concerns *

For example: The patient is presented with an impacted UL3. Please assess the need for an orthodontic treatment.

Attach relevant photos/ x-rays (optional)

Click or drag files to this area to upload. You can upload up to 8 files.

Please share any relevant X-rays to avoid double radiation exposure.

Acknowledgement & Consent

Terms & Policy *

By submitting this form, you agree to the clinic's Terms of Service and Privacy Policy.

Data sharing *

I confirm I have the requisite authority to share the patient's information in connection with this referral.

Please note that the patient you have referred will be fully assessed and offered a treatment plan based on the presenting condition in addition to a preventive care plan. *

I am happy for this patient to be offered an ongoing prevention plan at Sunrise Dental Clinic
I do not wish this patient to be offered an ongoing prevention plan at Sunrise Dental Clinic

Referral update regArding orthodontic treatment

After the orthodontic consultation, eligible patients will receive a detailed estimate containing the treatment plan and fees, with the option to share it with you if they agree.

consultation fee at Sunrise Dental Clinic:

*Orthodontic consultation with the Specialist Orthodontist/ £50

*Paediatric consultation with the Specialist Paediatric Dentist/ £200

*Paediatric consultation with Dentist with Special Interest in Paediatric Dentistry/)/ £150

*Consultation with Specialist Oral Surgeon/ £150

*Consultation with General Dentist/ £150

*Consultation Jaw Joint and occlusion Expert/ £150

*Hygiene First Visit/ £120

* Implant Consult is £100