Referral for Complex Restorative Dentistry

Referring to: Dr Iain Marrison

Vitality Fairfield Wellburn Road, Fairfield, Stockton-on-Tees, TS19 7PP

01642 587 646

iain.morrison@riverdalehealthcare.com

Please fill in this multi-part form below with as much detail as possible.

Fields marked with an * are required.

Dentist Name

Dental Practice

Practice Address

Phone Number

Patient Name

Patient Record Number (if existing RIverdale Patient)

Patient Address

Patient Phone Number

Patient Email

Date of Birth

Case Details

Is the patient dentally fit?

Yes No

For dental implants, does the patient have a bleeding on probing score of less than 10% and no pockets greater than 5mm?

Yes No

Shared Care Case?

Yes No

If YES, what part of the treatment will the referring dentist complete?

Have you uploaded Medical History?

Yes No

Have you uploaded Radiographs?

Yes No

Have you uploaded Photographs

Yes No

Upload Files (Must be .pdf, .jpg, .jpeg, .png)

Preferred contact method for referring dentist during treatment?

Email Phone WhatsApp/SMS Letter

Vitality Fairfield

Wellburn Road,
Fairfield,
Stockton-on-Tees
TS19 7PP

Referral for Complex Restorative Dentistry

Referring to: Dr Iain Marrison

Vitality Fairfield

01642 587 646

Out of hours – call practice number above

vfreception@riverdalehealthcare.com

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