Referrals

Refer a patient

Send patient details, clinical context, and supporting files securely to the Eastdale team.

For clinicians

Secure referral intake

Share the referral reason, useful clinical notes, and any radiographs, scans, photos, or PDFs you would like us to review.

Practice contact: 01483 555 012 | hello@eastdaledental.co.uk

Fields marked are required. All other fields are optional.

ReferrerClinician namePractice nameGDC number (optional)

Practice email (optional)Practice phone (optional)

Provide either practice email or phone (or both).

Practice address line 1 (optional)Practice address line 2 (optional)

City (optional)Postcode (optional)

Patient

First nameLast name

Date of birth (optional)Patient phone

Patient email (optional)Patient postcode (optional)

Preferred contact method (optional)PhoneEmailLeave blank if the patient has no preference.

Clinical contextReferral reason0 / 500Clinical notes0 / 2000I confirm the patient has consented to this referral and the sharing of the attached records.I confirm the referrer information supplied is accurate.

Attachments

Drop files here or .

Up to 20 files, 250.0 MB total.

Files stay on your device until you press Submit referral — they are uploaded securely as part of the submission.

No files yet. Add DICOMs, PDFs, or images.

Selected: 0 / 20 files · 0 B / 250.0 MB

Complete the verification check before submitting.