Referral Form


Please select your option

New Patient
New Patient
New Patient
CBCT Form

Please select the type of treatment from above

Name of Referrer:
Practice Name:
Email:
Telephone:
Address:
Name of Patient:
Date of Birth:
Address:
Telephone:
CLINICAL INDICATIONS (Please Complete) :
Is the patient coming with Radiographic Stent:
Is the patient possibly pregnant?:
PAYMENT BY:

COST: CBCT Single Arch £150, CBCT Both Arches £300, iTero Scan both Arches £150

Please select your preferred CBCT format:
File delivery options::

Note: Bluebell Dental Practice and Clinic do not routinely report on CBCT scans. To comply with the IRMER 2000 regulations all CBCT scans are required to be reviewed and reported in the clinical notes by the referring practitioner or by a radiologist.

Please select the type of treatment from above

Opinion only Opinion&treatment

(Please attach as a image(jpeg,jpg format), file size no greater than 1MB)



OPENING HOURS

Bluebell dental practice offers
Dentist chigwell

(NHS Opening Hours:

Mon: 9:00 am - 7:00 pm

Tue - Fri: 9:00 am - 5:00 pm)

Invisalign Authorised Credentials

1000
Diamond
itero
T

ADDRESS

Cosmetic dentistry chigwell
Bluebell Dental Pratice & Clinic
140 Tomswood Hill
Chigwell , Essex , IG6 2QP
chigwell@bluebelldp.co.uk
020 8500 6789
5 Star Rated Company

Bluebell Dental Practice is rated 4.5/5 based on 30 ratings & reviews on Google & NHS

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