Dental Treatment Referral Form | Vermilion Edinburgh

Patient Details

Date of referral*

Patient name*

Date of birth*

Address*

Postcode*

Phone/Mobile*

Patient Email

We're on a mission to reduce how much paper we use in our every day operations. As of July 1 2021, we will be moving from paper correspondence to digital. Please fill in your preferred email address, so that we can contact you with details about your treatment plan and more.

Nature of referral (please tick boxes)

Treatments*

Preferred Location*

Preferred Clinician*

Referral Notes*

Medical history*

Referring practitioner details

Name*

Address*

Telephone No.*

Referrer Email*

Please upload any radiographs or supporting files here

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 12 MB.

I consent to my submitted data being collected and stored*

This referred patient has consented to their submitted data being collected and stored*

I would like to opt-in to receive information on Vermilion's free CPD Programme, news and events.

To comply with patient data confidentiality, this referral form encrypts your information before it is sent securely to Vermilion via Comodo

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Email

This field is for validation purposes and should be left unchanged.

Make a Referral

Patient Details

Nature of referral (please tick boxes)

Referring practitioner details