Refer a patient | Courtrai House Dental | Henley

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Referrals
Referral form

Make a referral

To refer a patient to Courtrai House Dental & Implant Clinic, simply complete and submit the below referral form.

Please include all relevant clinical information regarding this case, and remember to attached any x-rays if relevant.

After reviewing, we will contact the patient to introduce ourselves and book them in. We will also keep you fully updated on progress throughout.

Patient details (step 1)

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First name *

Last name *

Address 1 *

Address 2 *

Postcode *

Date of birth *

Contact number *

Email *

Please check that the following fields have been filled out correctly:

Referring Dentist Details (step 2)

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First name *

Last name *

Phone number *

Practice name *

Practice address line 1 *

Practice address line 2

Practice city *

Practice county *

Practice postcode *

Email address *

Please check that the following fields have been filled out correctly:

Referral Details (step 3)

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Enter the name of the relevant clinician to refer your patient to (if known)

Treatment required *

Reason for referral/treatment required. Please detail relevant dental history and preferred clinician if applicable

General assessment of dental health

Oral hygiene *

Poor Fair Good Other

Teeth of poor prognosis *

Relevant medical history *

Additional files
- Please note that only the following file types are supported: jpeg, jpg, png, gif, pdf, doc, docx, xls, xlsx, rtf, ppt, odt.

Other records sent via post

Radiographs Study models Diagnostic wax up None Other

Final restoration to be placed by:

The Referring Dentist By Courtrai House Dental & Implant Clinic

Any comments

Confirmation

I confirm I have the requisite authority to share the patient's information in connection with this referral

Please check that the following fields have been filled out correctly:

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Courtrai House Dental & Implant Clinic and Portman Dental Care are trading names of Portman Healthcare Ltd, registered in England and Wales: 06740579. Registered office: Rosehill, New Barn Lane, Cheltenham, Glos, GL52 3LZ. Portman Healthcare Ltd is authorised and regulated by the Financial Conduct Authority as a credit broker under registration number 700090. Credit is subject to status and affordability, and is provided by Novuna Personal Finance a trading style of Mitsubishi HC Capital UK PLC. Terms & Conditions Apply. Portman Healthcare Limited is the controller of your data and registered with the Information Commissioners Office under registration number Z1929449

*Terms and Conditions: Courtrai House Dental & Implant Clinic is offering 10% off new patient dental health check-ups. This offer is available to new patients aged 18 and over only at Courtrai House Dental & Implant Clinic for appointments booked and attended between 10/02/2025 and 30/04/2025, who have not previously registered with the practice. Offer includes: a thorough dental health examination and two x-rays, if deemed necessary by the clinician. This offer is non-exchangeable, non-transferable, and is not redeemable for cash or other treatments and can only be redeemed once per new patient and cannot be used in conjunction with any other offer. Offer excludes additional dental treatment identified for the patient during the dental health check-up. If the patient requires additional treatment, an estimated course of treatment will be recommended to the patient. Appointments are subject to availability. Please note that the practice accepts no liability on behalf of the treating clinician and acts strictly as a liaison between the patient and the treating clinician only. Courtrai House Dental & Implant Clinic reserves the right to withdraw or change this offer at any time.

Copyright © 2025 Portman Healthcare. All rights reserved.

Last updated 07/06/2022 at 13:15

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