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Oxford House Dental Practice
Aylesbury Street
Fenny Stratford
Milton Keynes
MK2 2BA
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01908 373614
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I would like to:
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Book an Appointment
Straighten my Teeth
Replace Missing Teeth
Fix my Worn Teeth
Fix Gaps Between my Teeth
Replace my Dentures
Fix my Chipped Teeth
Fix my Broken Teeth
Have Whiter Teeth
Fix my Crooked Teeth
Have a Perfect Smile
Replace my Crowns
Replace my Veneers
Replace my Silver Fillings
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Treatment Referral Form
TREATMENT REFERRAL FORM
REFERRING DENTIST
Name of Practitioner
*
GDC Number
*
Practice Name
*
Address1
*
Address2
Phone
Practice Email
*
Personal Email
*
PATIENT DETAILS
Patient Forename
*
Patient Surname
*
Patient Address
*
Patient Date of Birth
Patient Email
Patient Telephone
Referral for
Endodontics
Oral Surgery
Periodontics
Dental Implants
IV Sedation
Orthodontics
Complex Restorative (GDP)
Facial Aesthetics
Other (Please State)
Other - Referral
Untitled
Any Treatment to be carried out by yourself? eg. Restoring Implant
Referral - Other Information
Urgent?
*
Yes
No
Referral details
Patient's Complaint
HISTORY
Oral condition
Excellent
Above average
Average
Below average
Poor
Periodontal state
Excellent
Above average
Average
Below average
Poor
Pain
Nil
Slight
Moderate
Severe
Swelling
Nil
Slight
Moderate
Severe
Medication/ Medical Alert
Documents and Radiographs
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Files
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Would you like this returned?
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Other relevant information
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Opening Times
Monday
8.00am - 5.30pm
Tuesday
8.00am - 5.30pm
Wednesday
8.00am - 6.00pm
Thursday
8.00am - 5.30pm
Friday
8.00am - 5.30pm
Saturday
8.00am - 2:00pm
Sunday
Closed
Contact details
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