Refer a patient

01

You, the referring practitioner

These details allow us to send you the clinical report.

Full name *

Practice (optional)

Professional email *

Phone *

02

The patient

We contact the patient directly to arrange the appointment.

Surname *

First name *

Date of birth (optional)

Patient’s phone number *

Patient’s email (optional)

Language of contact

The patient is aware of this referral and agrees to be contacted by our teams.

03

Your enquiry

The speciality, then the reason. Nothing else will be asked of you.

Speciality *

Endodontics by Dubois Root canal treatment and retreatment, under the operating microscope. Orthodontics by Becker Children, teenagers and adults — braces and aligners. Dental imaging by Dubois Panoramic X-ray, lateral cephalogram, Cone Beam and optical impression. Emergency care by Becker Pain, trauma, infection — care at short notice. Other request You are unsure where to refer, or your case involves more than one specialty.

Choose a speciality to see the reasons for referral.

04

Tooth (or teeth) concerned

FDI notation, practitioner’s view. Optional for a general referral.

05

Imaging and clinical information

X-rays, medical history, current treatment.

Attachments

Drop your files here, or click to browse JPG, PNG, PDF, DICOM, ZIP · 20 MB per file · 10 files maximum

Please send only the documents needed for the patient’s care.

Clinical comments

06

Consent and submission

Data protection. The information sent is processed solely for the care of the patient referred, hosted in Luxembourg and kept for the legal retention period applying to medical records. No data is used for commercial purposes, and this page sets no trackers. Full details in our privacy policy; questions to dpo@cabinet-becker.lu.

I confirm that I am authorised to share this data as part of the patient’s care. *

Send me a copy of this referral by email.

You, the referring practitioner

The patient

Your enquiry

Tooth (or teeth) concerned

Imaging and clinical information

Consent and submission

Referral sent

Patient referral

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Refer a patient

You, the referring practitioner

The patient

Your enquiry

Tooth (or teeth) concerned

Imaging and clinical information

Consent and submission

Referral sent