For Referring Dentists

Refer a Patient to Cedars Endo

Use our dedicated referral pathway to send patient and clinical information for specialist endodontic assessment or treatment.

Start a Referral Information for Dentists

Specialist Assessment Secure Referral Pathway Ascot, Berkshire

Referral Information

Specialist Referral Care

Endodontic Referral Form for Referring Dentists

Our endodontic referral form gives referring dentists a clear route to specialist assessment and treatment for patients who require endodontic care.

The endodontic referral form below collects patient, dentist and relevant clinical information through four clear stages: Patient, Dentist, Clinical and Review.

Providing complete information helps our specialist team review the referral and arrange the appropriate next step for the patient.

Secure Dentist Referral

Patient Referral Form

Please provide the information below to refer your patient for specialist endodontic assessment or treatment. Our team will review the referral and contact the patient directly to arrange their consultation.

1 Patient

2 Dentist

3 Clinical

4 Review

Patient Details

Please provide the patient’s details.

Patient First Name * Please enter the patient’s first name.

Patient Last Name * Please enter the patient’s last name.

Patient Email * Please enter a valid email address.

Patient Phone Number * Please enter a phone number.

Patient Phone Home Please enter a phone number.

Phone Work Number Please enter a phone number.

Patient Date of Birth * Date of birth must be entered in DD/MM/YYYY format only, for example 10/03/1952. If you type 10031952, the / separators will be added automatically. Please enter the date of birth.

Gender Please enter the gender.

Patient Address * Please enter the patient’s address.

Referring Dentist Information

Please provide the referring dentist’s details.

Dentist First Name * Please enter the dentist’s first name.

Dentist Last Name * Please enter the dentist’s last name.

Dentist Email * Please enter a valid email address.

Date * Please enter the date.

If this form is being completed by a practice staff, please give details Please enter the details.

Practice Name and Address * Please enter the practice name and address.

Preferred Contact No * Please enter a contact number.

Dentist Signature * Please enter the dentist’s signature.

Reason for Referral *

Please provide as much relevant information as possible as this helps us meet your patient needs expediently.

Please provide the reason for referral.

In the event the tooth is deemed unrestorable or the patient is interested in implant placement instead, do you consent for your patient to receive an implant assessment at Cedars Endo? *

Yes No

Please select Yes or No.

Clinical Details

Please provide the clinical information.

Priority *

Urgent Non Urgent

Please select the priority.

Radiograph *

To be sent by post To be emailed to reception@cedarsendo.co.uk

Please select the radiograph option.

Tooth / Teeth * Please enter the tooth/teeth.

Radiograph Upload Please upload a radiograph.

Radiograph 2 Upload Please upload a radiograph.

Radiograph 3 Upload Please upload a radiograph.

Review and Submit

Please review the key information below before submitting the referral.

Patient First Name Not provided

Patient Last Name Not provided

Patient Email Not provided

Patient Phone Not provided

Dentist Name Not provided

Dentist Email Not provided

Priority Not provided

Tooth / Teeth Not provided

Reason for Referral Not provided

Implant Assessment if Tooth Is Unrepairable Not provided

Privacy Policy

Before submitting this form please familiarise with our privacy policy and submit only if you agree with them.

I confirm that the patient has agreed to this referral and to Cedars Endo contacting them about their care. I confirm that the clinical information provided is accurate to the best of my knowledge. I understand that the submitted information will be used to assess, contact and care for the referred patient. Please confirm all three statements.

Data Protection and Security

Secure and Confidential Referral

Patient information must be processed securely and only accessed by authorised personnel for the purpose of managing the referral and providing clinical care.

UK GDPR Data Protection

NHS DSP Toolkit Security Standards Aligned

The displayed statements describe the intended data-protection framework for this referral service. Formal compliance depends on the practice’s policies, staff procedures, hosting, storage, access controls and published regulatory assessments.

Referral Support

Need Help With a Referral?

If you need help with the referral process, contact the Cedars Endo team at our Ascot practice.

Call 01344 283033 Information for Dentists

Practice Cedars Endo Address

The Lodge
17 London Road
Ascot
Berkshire
SL5 7EN

Telephone

01344 283033