FHDC is accepting referrals for Endodontics.

It is important for us to have correct information for all our referral patients. Please take time to complete the form and answer the following questions. Providing this information helps us treat our patients safely. All information provided will be kept strictly confidential.

Please complete this referral form & press the green send button below

Patient title(Required)

First Name(Required)

Surname(Required)

Phone(Required)

Your Email(Required)

Your address(Required)

Your postcode(Required)

Referring Dentist

Referring Dentist Name(Required)

Referring Practice Name(Required)

Referring Practice Number(Required)

Referring Practice Email(Required)

Communication

Please tick your preferred contact method(s) by the practice. This includes appointment reminders and general communication:

Communication(Required)

Phone via mobile

Phone via home

Notes

How can we help(Required)

If X-rays are available, please upload here...

Max. file size: 50 MB.

Please check the information is correct and click the send button below. By sending this information you are confirming that you agree to the disclaimer* below.

Thank you. Once you have clicked send, please wait a moment for any files to upload. If you do not receive an automatic email acknowledgement within a few minutes, there may have been an issue with your upload. Please try again or contact our reception team.

*By sending images via this website I hereby give permission for members of the FHDC team to upload and store this confidential patient information & images. I understand that www.fhdc.co.uk is a website and not FHDC’s internal dental practice management system and that whilst FHDC will use reasonable efforts to maintain the confidentiality of the information that is uploaded and sent electronically to FHDC, I also understand that FHDC CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR THE MISUSE OF UPLOADED INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED VIA THE INTERNET, THIS UPLOAD FEATURE ON THIS SITE OR ITS ASSOCIATED INTERNET SERVICES.

We are committed to protecting your personal information. Please see our privacy policy (opens in a new window) to find out how your information is stored and protected.

Endodontics Referral Form