PATIENT SELF-REFERRAL

Which service do you require? *

Title *

Name of the patient? *

First

Last

Gender *

Date of birth *

Address *

Address Line 1

City

State / Province / Region

Postal Code

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?

Name of parent/guardian *

First

Last

Current dental concerns *

Attach relevant photos/ x-rays

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

By submitting this form, you are aware of the consultation fee at Sunrise Dental Clinic

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

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