Dentist Referral

Referral Form

    Patient Details

    Best time to contact *

    Referrers Details

    Relevant Medical History

    DiabetesCardiovascular diseaseGastro-intestinal disordersBone/Joint diseaseBlood disordersAllergiesRespiratory disordersLiver diseaseKidney diseaseCancerPregnant

    Further Information

    Reason for referral:

    Further Information

    Your patient will be contacted via telephone or post at the earliest opportunity. A consultation costs £145 for a 60-minute appointment and includes any further investigations including radiographs, impressions and study models. A detailed report outlining the current diagnoses, prognoses and suggested treatment actions will be sent within 5 working days of the consultation.

    To book an appointment or to know more about our services, please call
    01582 712 470 or email us at

    Get in Touch

    Contact us with your questions or to request a ring back. We'd love to hear from you.

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