PATIENT SELF-REFERRAL

Which service do you require? *

Title *

Name of the patient? *

First

Last

Gender *

Date of birth *

Patient's address *

Please enter the full address, including the postcode

Phone *

Email address *

If the requested record relates to a child (under the age of 16 years), what is the relationship of the applicant to the child?

Current dental concerns *

Attach relevant photos/ x-rays

Click or drag files to this area to upload. You can upload up to 8 files.

Terms & Policy *

By submitting this form, you agree to the clinic's Terms of Service and Privacy Policy.

Data sharing *

I confirm I have the requisite authority to share the patient's information in connection with this referral.

*Orthodontic consultation with the Specialist Orthodontist/ Free

*Paediatric consultation with the Specialist Paediatric Dentist/ £200

*Paediatric consultation with Dentist with Special Interest in Paediatric Dentistry/)/ £150

*Consultation with Specialist Oral Surgeon/ £150

*Consultation with General Dentist/ £110

*Consultation Jaw Joint and occlusion Expert/ £150

*Hygiene First Visit/ £120