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Referral Form

    Patients Details

    Referring Dentist

    Relevant Medical History

    Current Medication

    Sedation Required*

    Please advise patients attending sedation that:
    i) IV sedation requires 4hr fast before treatment.
    ii) They must be accompanied by a responsible adult who can drive/transport them home AND supervise them for at least 6hrs after treatment.

    Proposed Treatment

    Any part of the treatment you propose to complete?

    Radiographs included?

    Radiographs type & number

    File attachments

    Any additional information?

    background

    Contact us today to book your appointment

    Call us on +44 28 4066 2034 or email info@cliffgardental.com

    Please note currently we are only registering patients for implant surgery (referrals and self refferals) our books are closed to all other treatment. We apologise for any inconvenience this may cause.