Practice information

Referring dentist name

Referring practitioner GDC number

Referring practice address

Referring practice telephone

Referring practice email

Patient information

Patient full name

Patient date of birth

Patient address

Patient telephone

Patient email

Clinical details

Medical history

Reason for referral

Does the patient require disability access?

YesNo

Is this for a REGO / DARS extraction?

YesNo

Important information

1. NHS Surrey will only pay for radiographs for patients with a requirement for diagnosis and NHS treatment of third molar cases in exceptional circumstances, with prior agreement. NHS Surrey may approve payment for a radiograph in NHS multiple extraction and complex restorative cases.

2. The referring practice will be liable for the cost of the radiograph (£65) if the request does not relate to referral criteria or the patient’s GP postcode is not on the list of addresses provided by NHS Surrey.

Please confirm that you have read the required information and that you are happy to proceed.