Referrals

1Referral Type

2Dentist Details

3Patient Details

Patient Details
Title
Patient Name
GDC No
Gender
Date of Birth
DD slash MM slash YYYY
Address
Street Address Address Line 2 City Postcode
Telephone*
Mobile*
Email
Relevant Medical Details*
Short summary of case*
COCO Dental Care aim at assisting professionals and patients in diagnosis and treatment planning. COCO Dental Care is not providing and is not responsible for providing any interpretation of images or clinical service such as diagnosis or treatment. COCO Dental Care endeavours to provide the very highest quality results, however COCO Dental Care will not accept any liability for incorrect or incomplete information on the referral form or inappropriate or inadequate patient preparation which may compromise the value of the final results. By referring a patient, the referring practitioner agrees to the terms of the COCO Dental Care standard Service Level Agreement. COCO Dental Care endeavours to despatch the images to the referrer and/or the patient as quickly as possible, however e.g. equipment malfunction may introduce delays. COCO Dental Care reserves the right not to accept referrals in such cases. COCO Dental Care must be notified 24 hours in advance of the patient’s visit to the imaging centre if a particular urgent service is required.

Dentist Details