Patient Referral Form

Please fill in the form below & we will be in touch as soon as possible
Refer your patient to us at Vitality Dental for private oral surgery and sedation and rest assured that you will be kept up to date at every step of the way. Once your patient has completed treatment, they will be referred back to you to continue with their general dental care and maintenance.

    (* Fields with an asterisk are required)
    Patient Details
    Address
    Would you like the patient to see a specific dentist?
    YesNo
    Type of Referral* (Please tick all boxes that apply)
    RestorativeUrgentIV/RASedationOral SurgeryImplant(s)OPTCT Scan
    Oral Surgery: Reason for referral*
    X-rays / Any other relevant files enclosed?*
    YesNo
    Has the patient been referred before?*
    YesNo
    Any relevant medical history?*
    YesNo
    Referring Practitioner Details*
    Referring Clinic Address*
    Any Other Information

    Our address

    Vitality Dental Care
    5/3 Bristo Square
    Edinburgh
    EH8 9AL

    Telephone:

    0131 629 1120

    Opening times:

    Monday to Friday9.30am to 6.00pm

    Saturday 9.30am to 2.30pm