Refer A Patient

Over 100+ Reviews

Please use the form below to refer a patient to Clinic. Alternatively, you can always Contact us to discuss your referral.

Fields marked with a * are mandatory

Referring Dentist Name*

Referring Practice*

Referring Dentist Email

Patient Name*

Patient Address*

City

Country

postcode

Patient Contact Number*

Patient Email

Patient Date Of Birth

Reason for referral*

Relevant Medical History*

Drop Files Here Or

SELECT FILES

Upload radiographs and images of the case in the following formats jpeg, jpg, gif, giff, png Up to 5 images allowed, max size 3MB per image

Over 100+ Reviews

If you are a Practice Plan Member please call 0808 169 8117 if you are overseas please call (0044) 1691 887955.

Or contact 111 for advice if your not a Practice Plan Member

3 Belmont Terrace, Terrace Road, Buxton SK17 6DZ