Referral for Endodontic Treatment

Referring to: Mihai Neacsu

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

01642 587 646

tcofairfield@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

Reason for referral

Restorative Dentistry Root Canal Treatment

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

01642 587 646

Out of hours – call practice number above

vfreception@riverdalehealthcare.com

FREE Consultation

Book a video consultation

Dentist Area

Quick online referrals

0% Finance Available

Spread the cost of your treatment

Dental Plans

Spread the cost of general dental care

Contact Us

Get in touch, we’d love to hear from you

FREE Consultation

Book a video consultation

Dentist Area

Quick online referrals

0% Finance Available

Spread the cost of your treatment

Dental Plans

Spread the cost of general dental care

Contact Us

Get in touch, we’d love to hear from you

Vitality Dental Care provide private dental treatment
and are proud to serve Stokesley, Ormesby, Guisborough,
Middlesbrough and the surrounding areas in North Yorkshire.

Treatments

Riverdale TradeCo Ltd trading as Vitality Dental Care is a credit broker, authorised and regulated by the Financial Conduct Authority. Registered in England & Wales 11506562

Where required by law, loans will be regulated by the Financial Conduct Authority and the Consumer Credit Act. Credit is provided by Wesleyan Bank Limited who is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Wesleyan Bank Ltd (Registered in England and Wales No 2839202) Registered Office: PO Box 3420, Colmore Circus, Birmingham B4 6AE. Tel: 0800 358 1122. www.wesleyanbank.co.uk Terms and conditions apply.