PATIENT SELF-REFERRAL – Orthodontist Dr Mo Dentist Dr Libi Edinburgh UK | Sunrise Dental Clinic Orthodontic & Paediatric Dentistry

Which service do you require? *

Paediatric Dentistry Assessment
Orthodontic Assessment
Oral Surgery Assessment
Cosmetic Dentistry Assessment
Prosthetic Replacement Assessment
Facial Pain & Jaw Joint Assessment
General Dental Services
Other Dental Services

Patient level of anxiety *

Anxious
Non-anxious

Patient details

Title *

Name of the patient? *

First

Last

Gender *

Date of birth *

Patient's address *

Address Line 1

City

State / Province / Region

Postal Code

Please enter the full address, including the postcode

Phone *

Email address *

Other relevant details

Is this referral related to another person? *

What is your relationship as applicant to the patient? *

For example mother, father, legal guardian, spouse, etc.

Please write your name as applicant *

First

Last

Do you have a family member (like a parent, partner, or sibling) who are registered at Sunrise Dental Clinic? *

Please name the family member(s) who is/ are currently registered at Sunrise Dental Clinic. *

Details of the referral purpose

Current dental concerns *

For example: My top left wisdom tooth is causing severe pain, and I want to assess its condition and explore treatment options.

Attach relevant photos/ x-rays (optional)

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

Acknowledgement & Consent

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.

Booking deposit *

I agree that a £50 deposit is required to book appointments and is refundable if the cancellation and no-show policies are followed.

consultation fee at Sunrise Dental Clinic:

*Orthodontic consultation with the Specialist Orthodontist/ £50

*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

Dental/ medical practitioners update regArding orthodontic treatment

After the orthodontic consultation, eligible patients will receive a detailed estimate containing the treatment plan and fees, which they can share with their dental/ medical practitioners if they wish.