Referrals

At Mint Clinic we work exclusively in periodontal and implant treatment. As we don’t compete with your business, if you refer a patient to us, you can rest assured that they’ll remain in your care. We aim to treat the presenting complaint and refer your patient back into your continuing care on completion of their treatment. We do not refer patients onto other specialists without prior permission from the referring Dentists.

Tel: (01) 678 9904 or email us

Referral Form

Date*

Patients name*

Contact number*

Date of birth

Reason's for referral

Tooth number(s)

Radiographs

Periodontal evaluation

Periodontal treatment completed to date

Upload File

Referring Dentist’s name*

Practice name*

Practice Contact number*

Email*

Have you advised patient of the possibility
of tooth extraction?
NoYes, tooth number

Is there any restorative dentistry that needs
to be competed?
NoYes, comment

Comments

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