Ballymena Online Referral Form Appointment Date (dd/mm/yy): If already booked Appointment Time: If already booked/ Patient Name: DOB (dd/mm/yyyy): CHI: Address Line 1: Address Line 2: Mobile/Tel No#: Relevant Medical History: Would you prefer this patient to be seen by a particular clinician? yesno If Yes which clinician?: RA SEDATION: yesno IV SEDATION: yesno (Patients having I.V. sedation should fast for 4 hours prior to appointment and be accompanied by a responsible adult, who can take them home and look after them for approx. 6 hours following treatment.) Procedure: Teeth: Payment Source: NHSPrivate Referring Dentist Name: Referring Dentist Email: Attach Patient x-rays if available (File types - jpg, gif, png, doc, pdf): We recognise that when you give us personal information (which includes health information) you’re trusting us to take good care of it. Please see www.bupa.co.uk/privacy for more information about how we collect, use and protect your data. If you don’t want to receive marketing about Bupa products and services that we think are relevant to you, please contact us at firstname.lastname@example.org.