Refer a Patient

If you would like to refer a patient to Dental Health Spa please fill out the following form and we will contact the patient by telephone or email during our working hours: 

Monday:

12:00 – 20:00

Tuesday:

09:00 – 18:00

Wednesday:

09.00 – 18:00

Thursday:

09:00 – 20:00

Friday:

09:00 – 16:00

Saturday:

09:00 – 15:00

Sunday:

Closed

If they require an appointment within the next 24 hours please contact us on 01273 710831.

Alternatively you can download a copy of our referral form:

Dentist Referral Form Dentist Referral Form (154 KB)

When you have completed the form please call us to book an appointment on 01273 710831, then fax the form to 01273 710820, or post to Dental Health Spa, 14 – 15 Queens Road, Brighton, BN1 3WA.

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Referring dentist's details

Practice name:
Practice address:
0 /
Phone no.:
GDC no.:

Patient details

Full name:
Last Name:
Address:Street
City
County
Post Code
Phone No:
Date of birth:

Treatment plan - criteria for referral

If YESaverage number of cigarettes smoked per day:

BPE: Periodontal Examination

Code: 

0 =No bleeding on probing
1 =Pockets <4mm & bleeding on probing
2 =Pockets <4mm, BOP & plaque retentive factors
3 =Pockets 4 & 5 mm
4 =Pockets at least 6mm
# =Pocket recession at least 7mm in total: fucation involvement
Dental Health Spa to take BPE?:
Dental Health Spa to take x-rays?
Specific observations:
0 /
Referral options:
0 /

Dental Health Spa appointment

Preferred date:
Preferred time:
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