Routine and Complex Dentistry

Referrals

For referrals, please complete the form below, or click here to download the form and then scan and email it to info@stuartgrahamdentist.co.uk.

Referring dental practitioner:
Address/contact phone number:
Referring practitioner email:
Patient's name:
Male
Female
Patient's address
Patient contact phone number:
Patient contact email address:
Patient's main complaint:
Referring practitioners request of care and comments:


Medical History Yes No Details
Diabetes
Radiotherapy
Allergy
Smoker
Steriods
Chemotherapy
Bleeding Disorders
Drugs
Other


Radiography images
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Image 2:
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Image 4:
Image 5:
Name
GDC No
Date
If you would like us to call you back to discuss this case, please tick the box.


E: info@stuartgrahamdentist.co.uk


Treatments



Referrals

To refer a patient to us, click here to complete or download our referral form.


Practice Details

Graham Porter Caring Dentistry
8/9 Castle Green
Green Lane
Cottingham
HU16 5JU

Telephone Number: 01482 841146

GDC Reg Number: 59133