Content on this page requires a newer version of Adobe Flash Player.

Get Adobe Flash player

Dentist referrals

Simply fill in the referral form opposite and our friendly Treatment Coordinator, Laura, will be in touch with your private patient to arrange a consultation for them. Alternatively, your patient can call 0845 872 8777 between 8am and 4.30pm, Monday to Friday and speak to Laura directly, or fill in our easy self-referral form themselves.

For your NHS patients, please ensure that they will not have turned 18 before their treatment commences (for waiting times, please contact the practice on 0845 872 8777).

*Required fields-1

Referral type: NHS/Private

Patient Details

 
*Full name:
Title
*Sex
*DOB
Parent's full name (if under 18)
*Contact telephone number
Other telephone number
*Email address
*Home address
*Postcode

Dentist details

 
*Referring dentist, full name
*Dental practice
*Contact number
*Email address:
Any other information :