Name: Rally Agency Ltd
Price range: $

For private referrals, please complete the below form. For NHS referrals, instructions for the correct route will be displayed when selecting the practice, or by completing the form if it is displayed.

NHS or Private?

NHS

Private

Practice *

Our referrals are handled by the REGO system, please log in at https://ref.management/login or contact us for assistance.

Referrals are handled by the SCI Gateway system. Please refer all patients using your desktop application.

Please refer cases using https://www.england.nhs.uk/south/info-professional/dental/dcis/forms

Our referrals are handled via post or by using the Referral Management Service: https://rms.cornwall.nhs.uk/information_for_gdps__dental_practices

Treatment *

Clinician Enter the name of the relevant clinician to refer your patient to (if known)

Your details

Title *

First name *

Last name *

Practice name *

Practice address line 1 *

Practice address line 2

Practice city *

Practice county *

Practice postcode *

Practice phone number *

Practice email address *

Patient details

Title

First name *

Last name *

Address 1

Address 2

Postcode

Date of birth *

Contact number

Email *

Relevant medical history *

General assessment of dental health

Oral hygiene *

Poor

Fair

Good

Other

Teeth of poor prognosis? *

Reason for referral *

Confirmation

I confirm I have the requisite authority to share the patient's information in connection with this referral

Referral form

Your details

Patient details

General assessment of dental health