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Patient Details

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Patient Name*
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Address*
We are committed to reducing paper use in our daily operations. Since July 2021, we have transitioned from paper correspondence to digital communication. Please provide your preferred email address so we can send important updates and details about your patient’s treatment plan.

Patient Referral

Nature of Referral*
To ensure prompt processing of your referral, please include any supporting X-rays. If you have a CBCT scan, kindly email it to smile@vermilion.co.uk for our Edinburgh clinic or kelso@vermilion.co.uk for our Kelso clinic.*

Referring Practitioner Details

RDP Name*
Clinic Address*
Please use your work email address when submitting patient referrals and not your personal email address.
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    I consent to the collection and storage of my submitted data and I agree to be contacted by Vermilion for enquiries.*
    This referred patient has consented to their submitted data being collected and stored.*
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