MAKE A REFERRAL

PATIENT REFERRAL FORM

1. PATIENT DETAILS

Reason for referral

2. REFERRER DETAILS

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3. ATTACHMENTS

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Ritu Gupta and Stephanie Bryan, Orthodontists

SERVICES OFFERED TO REFERRING DENTISTS

PANORAMIC X-RAY (OPT)

Referrals for OPT x-rays can be carried out privately for a fee to the patient of £50. Simply send us a referral form with a detailed justification (online or paper).

CASE DISCUSSIONS/INFORMAL OPINION

If you have any queries about referring your patient for a consultation, we would be happy to discuss it with you. Some dentists regularly email radiographs or photos (with the patient’s consent) for a quick opinion. Remote consultations can offer an opportunity to discuss tricky cases.

CONTACT

01243 786620

info@chichesterorthodonticclinic.co.uk

20 Westgate, Chichester

West Sussex, PO19 3EU

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