Refer to us

We are happy to welcome all referrals to help you manage the needs of your patients. Patients will be cared for professionally by our friendly specialist dental team and returned to the referring dentist upon completion of treatment. We will keep referring dentists fully informed of the progress of their patients’ care.

 

Our promise to you… ALL patients will be returned to your care after completion of treatment. NO patients will be allowed to be taken on for their general dental care at the practice. NO treatment other than that referred for will be carried out without the express permission of the referring dentist.

dental clinic
Download Referral Form

Patient's Details

Title of patient *

First Name of patient *

Surname of patient *

Patient's e-mail address *

Gender of patient *

MaleFemale

Date of birth of patient *

Address *

Contact Number *

Optional Contact Number


Patient's Details

Name of referring dentist *

E-mail of referring dentist *

Name of referring practice *

Practice postcode *

Practice phone number *

Patient's dental plan

Tooth in Question *


Patient history and treatment required

Treatment required *

Status of condition (tick all that apply)

SwellingPulp exposed and bleedingDressing and temporary filling insertedTooth opening for drainageEndodontic treatment startedElective endodontic treatmentPermanent bridge/crown is cementedPatient has discomfortPatient is likely to require sedation

If your condition is not listed above, please give details below

Is condition urgent? *

YesNo

Please give any more details

Dental treatment given to date

Relevant medical history

Patient history and treatment required

Permission to perform further treatment other than the treatment requested by GDP if required? *

YesNo

Please give any more details

Have radiographs been taken? *

YesNo

Upload images

Please choose your marketing contact preference: *

EmailDirect MailOnline advertising
Yes I consent to my personal data being collected and stored as per the Privacy Policy.
Yes I consent to my personal data being collected and stored for the purpose of marketing communications.