• About you

• Name*
  Let us know who is filling in this form.
  First Last
• Are you a*
  • Dentist - contract holder
  • Dentist - associate
  • Practice manager
• What is the name of your practice?*
• Will you be the main contact for referrals from your practice?
  • Yes

• Address

• Post Code
• Get Addresses
• Post Code is required.
• Address*
  ----------
• Address 1
• Address 2
• Address 3
• Address 4
• Address 5
• Address 6
• Address 7

• Your IT status

• Your internet connection
  Tell us about how you connect to the internet from your practice?
  • We have high speed broadband in the practice
  • We have broadband in the practice
  • We cannot access the internet in the practice
• Accessing websites*
  Can you access the dental referral website from your practice?
  • Yes - we can access the website
  • No - we can't access the website from the practice
• Practice IT system*
  Tell us what, if any, practice software you use in your practice. This helps us provide you with integration modules to make referrals easier.
  • We dont use practice software
  • R4 / Carestream
  • Software of Excellence - EXACT
  • Dentally
• Radiographs*
  We want to understand how you might be able to send your radiographs to us. We can provide you with a free scanner if you have film based radiographs.
  • I have digital radiographs and will upload them
  • I have film based radiographs and want to scan and send them
  • I have film based radiographs that I would want to post to you
• Dental Radiograph Scanner
  We would like to provide you with a small, USB dental scanner for intra-oral films. Would you like one of these for your practice?
  • Yes - please send me one with instructions
  • No - I have another means of scanning films
• Concerns
  We recognise that moving to electronic referrals can be concerning for practices. Let us know what concerns you might have about the process, the technology or any other aspect of the system?
• Early adopters*
  We have found that many practices are keen to get started and want to learn more about the system. If you are interested in being one of the first practices to get started, please let us know.
  • Yes - sign me up
  • No - we will wait
• Email address*
  Let us know the email address that you would like to use and we will be in touch with your login details.
• Phone number*
  We will send you a passcode by email or SMS text message when you login to the referral system. Please give us one phone number to use for now - you will be able to add more later.

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