DENTIST REFERRAL

This form is for the use of dentists to refer their patients to us for orthodontic treatment.

PATIENT REFERRAL FORM

1. PATIENT DETAILS

PLEASE NOTE: WE CAN NOT ACCEPT THIS REFERRAL UNLESS ALL FIELDS HAVE BEEN COMPLETED

Reason for referral

Private assessment

OPT only

Informal opinion

2. REFERRER DETAILS

Please send me more business cards

3. ATTACHMENTS

Upload any relevant photos and x-rays

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Max File Size 15MB

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Thank you, your referral has been sent to us. You will receive a copy of this referral by email.

SERVICES OFFERED TO REFERRING DENTISTS

PANORAMIC X-RAY (OPT)

Referrals for OPT x-rays can be carried out privately for a fee to the patient of £60. Simply send us a referral form with a detailed justification (online or paper).

CASE DISCUSSIONS/INFORMAL OPINION

If you have any queries about referring your patient for a consultation, we would be happy to discuss it with you. Some dentists regularly email radiographs or photos (with the patient’s consent) for a quick opinion. Remote consultations can offer an opportunity to discuss tricky cases.