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
Would you like the patient to see a specific dentist?
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?*
Has the patient been referred before?*
Any relevant medical history?*
Referring Practitioner Details*
Referring Clinic Address*
Any Other Information

Our address

Vitality Dental Care
5/3 Bristo Square


0131 629 1120

Opening times:

Monday to Friday9.30am to 6.00pm

Saturday 9.30am to 2.30pm

Dear patients,


```COVID-19 Emergency Protocol```


Unfortunately due to unforeseen circumstances amidst the COVID-19 pandemic, we have been advised to temporarily vacate our premises.

We have contingency plans in place for our patients and two of our buddy/sister (practices both within 1 mile of our location) will be seeing our emergency patients.

Therefore, from 24th March 2020 we will now only be assessing emergency patients through our telephone triage service. If you are an existing patient and your emergency qualifies then you will be seen at our local buddy/sister practices.

We apologise for any inconvenience and are grateful for your patience in this very difficult time.

Many thanks.

Wishing you all the very best of health. Stay safe.

The Vitality Family