Dentist Referral

"*" indicates required fields

Referring Dentist Details:

Referring practitioner’s name*

Practice telephone*

Practice address*

Practice email*

Referred Patient Details:

Date of decision to refer*

Patient first name*

Patient surname*

Patient gender*

Patient date of birth*

Patient contact telephone number*

Patient email*

Patient full address*

Name of parent/guardian*

Sibling already registered with us*

Referral Details:

Relevant details:**

I confirm that the patient has good oral hygiene

I confirm that the patient is carries free

By ticking these boxes you, the referring GDP, is agreeing to the patients OH/caries status being of an acceptable standard for Orthodontic treatment to commence. We will NOT be able to start treatment if these two boxes are not ticked.

I confirm I have gained consent from the patient/parent to make this referral

Consent has been given for the patient/parent to be contacted via email and/or SMS

I confirm that patient has been informed of private consultation fee of £40

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