Twenty One dental clinic dentist New Church Road Brighton Hove

Clinical Referrals

WHY CHOOSE TWENTYONEDENTAL?

A clinic that you and your patients can trust
We believe in providing outstanding treatment using only the highest quality materials and equipment, based on clinical evidence
Our clinical care team are highly skilled professionals with an exceptional reputation
Same day appointments available
Free on-site parking for your patient
Convenience of early morning and late night appointments

WORKING IN PARTNERSHIP

TwentyOneDental believe in working in close partnership with you, the referring dentist. By doing this, we are able to complement your services and broaden the range of treatment options available for the benefits of your patients.

You can be confident in using our services as we provide an assurance that we will only treat patients for the issue they have been referred, ensuring that they are returned to your care upon completion of their treatment.

WOULD YOU LIKE TO DISCUSS THE CASE YOU ARE REFERRING?

Should you prefer to initially discuss a case you wish to refer to us, please telephone our private referrals coordinator Kayleigh Pizzey on 01273 202102. Alternatively, you can email at the following address kayleigh@twentyonedental.co.uk. Kayleigh oversees all private referrals to our clinic and will be very happy to help organise this for you.

Kayleigh Pizzey

TREATMENT & PRIVATE REFERRALS COORDINATOR

Kayleigh is our dedicated and extremely experienced Treatment (including patient finance) & Private Referrals Coordinator.

Privileged to have Kayleigh compliment our exemplary team members with her considerable knowledge and extremely high skill set of all our leading dental treatments and options available. Such experience really helps understand specific patient requirements in order to achieve the smile they want and truly deserve.

Imaging

Imaging Referral

Patient Details

Forename:

Surname:

D.O.B:

Phone No:

Address

Email:

Referrers Details

Forename:

Surname:

Phone No:

Email:

Address

History

Relevant Medical History:
Is/could the patient be pregnant:
Date of last examination:
Please upload any attachments you wish to add:

Area of Interest (CBCT Only)

Please click on the tooth notation relating to the area of interest (must specify tooth*)

Upper Right

87654321

Upper Left

12345678

Lower Right

87654321

Lower Left

12345678

MaxillaBoth JawsMandibleSectional

Small Volume
YesNo

Specific Volume Size
80mm x 80mm50mm x 80mm80mm x 50mm50mm x 50mm

Main Complaint/Reason for Referral:

Examination Required

Digital PanoramicCone Beam CT3D Face Mapping (Planmeca Pro Face) – *This can be carried out with the CBCT scan – No ionising radiationWill patient wear a radiographic stent?

Software Delivery

We supply Romexis One Viewer, fully functional software with every scan.

The CBCT scans are delivered via Romexis Cloud using 256 Bit encryption for all data and transfers.

DPT’s delivered via email.

Clinical Indications (Justification under IR(ME)R 2017)

Dentist Signature:

Referral Date:

* all fields must be completed before submitting this form

I’d like to be informed of exclusive offers and other practice information Yes

*By Clicking ‘Send’ You Are Consenting To Us Replying, And Storing Your Details. (see our privacy policy).

Oral Surgery

Oral Surgery Referral

Patient Details

Forename:

Surname:

D.O.B:

Phone No:

Address

Email:

Referrers Details

Forename:

Surname:

Phone No:

Email:

Address

History

Relevant Medical History:
Date of last examination:
Please upload any attachments you wish to add:

Area of Required Treatment

Please click on the tooth notation relating to the area of interest (must specify tooth)

Upper Right

87654321

Upper Left

12345678

Lower Right

87654321

Lower Left

12345678

Status & Required Treatment

(Please tick all that apply)

Assessment and AdviceComplex Surgical ExtractionApicectomySinus Lift ProcedureTunnel GraftingSoft Tissue GraftingImpacted Third Molar ExtractionFranectomy

Assessment & Advice

Is sedation required?

If yes, please complete the sedation referral form.

Main Complaint/Reason for Referral:

Dentist Signature:

Referral Date:

* all fields must be completed before submitting this form

I’d like to be informed of exclusive offers and other practice information Yes

*By Clicking ‘Send’ You Are Consenting To Us Replying, And Storing Your Details. (see our privacy policy).

Implants

Implant Referral

Patient Details

Forename:

Surname:

D.O.B:

Phone No:

Address

Email:

Referrers Details

Forename:

Surname:

Phone No:

Email:

Address

History

Relevant Medical History:
Date of last examination:
Please upload any attachments you wish to add:

Area of Required Treatment

Please click on the tooth notation relating to the area of interest (must specify tooth)

Upper Right

87654321

Upper Left

12345678

Lower Right

87654321

Lower Left

12345678

Status & Required Treatment

(Please tick all that apply)

Surgical Implant PlacementSinus Lift ProcedureRestoration of ImplantSoft Tissue Grafting

Main Complaint/Reason for Referral:

Dentist Signature:

Referral Date:

* all fields must be completed before submitting this form

I’d like to be informed of exclusive offers and other practice information Yes

*By Clicking ‘Send’ You Are Consenting To Us Replying, And Storing Your Details. (see our privacy policy).

IV Sedation

IV Sedation Referral

Patient Details

Forename:

Surname:

D.O.B:

Phone No:

Address

Email:

Referrers Details

Forename:

Surname:

Phone No:

Email:

Address

History

Relevant Medical History:
Date of last examination:
Please upload any attachments you wish to add:

Area of Required Treatment

Please click on the tooth notation relating to the area of interest (must specify tooth)

Upper Right

87654321

Upper Left

12345678

Lower Right

87654321

Lower Left

12345678

Status & Required Treatment

(Please tick all that apply)

Intravenous SedationIntranasal Sedation

Has the patient had IV Sedation before?
IF YES: did the patient suffer any reactions or unexpected effects?
IF YES: Please elaborate:

Main Complaint/Reason for Referral:

Dentist Signature:

Referral Date:

* all fields must be completed before submitting this form

I’d like to be informed of exclusive offers and other practice information Yes

*By Clicking ‘Send’ You Are Consenting To Us Replying, And Storing Your Details. (see our privacy policy).

Short Term Orthodontics

Short Term Orthodontics Referral

Patient Details

Forename:

Surname:

D.O.B:

Phone No:

Address

Email:

Referrers Details

Forename:

Surname:

Phone No:

Email:

Address

History

Relevant Medical History:
Date of last examination:
Please upload any attachments you wish to add:

Area of Required Treatment

Please click on the tooth notation relating to the area of interest (must specify tooth)

Upper Right

87654321

Upper Left

12345678

Lower Right

87654321

Lower Left

12345678

Status & Required Treatment

(Please tick all that apply)

Six Month SmilesInvisalign LiteInvisalign FullInvisalign i7

Main Complaint/Reason for Referral:

Dentist Signature:

Referral Date:

* all fields must be completed before submitting this form

I’d like to be informed of exclusive offers and other practice information Yes

*By Clicking ‘Send’ You Are Consenting To Us Replying, And Storing Your Details. (see our privacy policy).

Endodontics

Endodontic Referral

Patient Details

Forename:

Surname:

D.O.B:

Phone No:

Address

Email:

Referrers Details

Forename:

Surname:

Phone No:

Email:

Address

History

Relevant Medical History:
Date of last examination:
Please upload any attachments you wish to add:

Area of Required Treatment

Please click on the tooth notation relating to the area of interest (must specify tooth)

Upper Right

87654321

Upper Left

12345678

Lower Right

87654321

Lower Left

12345678

Status & Required Treatment

(Please tick all that apply)

Acute symptoms, pain or swellingTooth is open for drainageRe – Root Canal TreatmentPulp exposed and bleeding (temp filling)Post removalCrowned ToothTemporary filling?Permanent restorationApicectomy

Assessment & Advice

Is sedation required?

If yes, please complete the sedation referral form.

Main Complaint/Reason for Referral:

Dentist Signature:

Referral Date:

* all fields must be completed before submitting this form

I’d like to be informed of exclusive offers and other practice information Yes

*By Clicking ‘Send’ You Are Consenting To Us Replying, And Storing Your Details. (see our privacy policy).

Periodontist

Periodontist Referral

Patient Details

Forename:

Surname:

D.O.B:

Phone No:

Address

Email:

Referrers Details

Forename:

Surname:

Phone No:

Email:

Address

History

Relevant Medical History:
Date of last examination:
Please upload any attachments you wish to add:

Area of Required Treatment

Please click on the tooth notation relating to the area of interest (must specify tooth)

Upper Right

87654321

Upper Left

12345678

Lower Right

87654321

Lower Left

12345678

Status & Required Treatment

(Please tick all that apply)

Untreated periodontal diseaseTreated/Non-Responsive periodontal disease (residual bleeding pockets of 4mm or greater)Peri-Implant disease (Peri-Implant mucositis/Peri-Implantitis)Gingival hypertrophy/hyperplasiaGingival recessionGummy smile (aesthetic crown lengthening)Pre-Restorative crown lengtheningMedication associated periodontal diseaseOral manifestation of systemic conditionsMucogingival conditionsNon-Plaque-Induced periodontal disease (e.g. Viral/Autoimmune/Vesiculo-bullous)Advice or Opinion on in-remission cases

Assessment & Advice

Is sedation required?

If yes, please complete the sedation referral form.

Main Complaint/Reason for Referral:

Dentist Signature:

Referral Date:

* all fields must be completed before submitting this form

I’d like to be informed of exclusive offers and other practice information Yes

*By Clicking ‘Send’ You Are Consenting To Us Replying, And Storing Your Details. (see our privacy policy).

We look forward to welcoming you into our friendly clinic

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