Working in partnership with our referring dentists

Our promise to you

We value the trust you place in us with looking after your patients and guarantee that we will keep you informed of their treatment at all times and place them back in your care when the treatment they have been referred to us for has been completed.

Making a referral

Our highly experienced clinicians here at The Dental Surgery accept referrals in the following:

• Periodontics (including receding gums)
• Endodontics
• Orthodontics
• Implants
• Radiographs – OPG / CBCT (unreported)
• Extractions
• Dental Hygiene
• Facial Aesthetics

 

We’re currently working on a new referral Portal, so to make a referral in the meantime, please contact us on 020 7680 1800 or complete the referral form below and we will be in contact with you.

Make a referral

Patient details (step 1)

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First name *

Last name *

Address 1 *

Address 2 *

Postcode *

Date of birth *

Contact number *

Email *

Please check that the following fields have been filled out correctly:

Next stage

Referring Dentist Details (step 2)

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First name *

Last name *

Phone number *

Practice name *

Practice address line 1 *

Practice address line 2

Practice city *

Practice county *

Practice postcode *

Email address *

Please check that the following fields have been filled out correctly:

Next stage

Referral Details (step 3)

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Enter the name of the relevant clinician to refer your patient to (if known)

Treatment required *

Please select... General Dentistry Emergencies Hygienist Teeth Whitening Teeth Straightening Invisalign Fixed Braces Children’s Orthodontic treatment Teeth Restoration Root Canal Teeth Replacement Dental Implants Dentures Dental Bridges Periodontics Cosmetic dentistry Veneers Facial Aesthetics Anti-wrinkle treatment Dermal Fillers Profhilo Microneedling

Observations & Dental History

General assessment of dental health

Oral hygiene *

Poor Fair Good Other

Teeth of poor prognosis *

Relevant medical history *

Additional files
- Please note that only the following file types are supported: jpeg, jpg, png, gif, pdf, doc, docx, xls, xlsx, rtf, ppt, odt.

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Confirmation

 I confirm I have the patient's consent to share this information

Please check that the following fields have been filled out correctly:

Finish

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