Referral Guarantee A clinician accepting a patient on referral will only undertake treatment they feel to be appropriate and that which lies within their competency. If the accepting clinician feels that alternative or additional treatment is required, this will be discussed with both the referring clinician and the patient and consent obtained for an amended treatment plan and any costs involved. Unless otherwise agreed with the referring clinician the accepting clinician will only carry out treatment in the capacity for which the patient has been referred to him/her. Patient Name Surname House No. & Street Name City Postcode DOB Email Home Number Mobile Number Referral Notes Has this patient been referred to before YesNo Type of referral Please arrange an appointment for: ExtractionAlveoplastyApicectomyFrenectomyExposureDermal FillerBone GraftingSinus LiftingDerma FillersImplantsPre-Prosthetic Surgery Anaesthetic: Local AnaestheticIV Sedation Referring Dentist/Doctor Surname Address Address2 Postcode Email Telephone Number Send