Refer your patient

REFERRING PROVIDERS DETAILS

* Indicates required field

Referral Provider Name *

First

Last

Contact Telephone Number *

Address of Referee *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Title of Patient *

Contact Telephone Number of Patient *

Name of Patient *

First

Last

Email of Patient *

Address of Patient *

Line 1

Line 2

City

State

Zip Code

Country

Are you happy for us to contact patient directly? *

TYPE OF REFERRAL *

Referral Proforma *

Please feel free to contact us at any time, if you have any questions or queries, or if you would like to discuss any aspect of the treatment. All patients will be referred back to referring practitioner unless requested otherwise.

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Referral Price Guide List (please be aware this is subject to change and conditions, for the most relevant up to date price list please contact the clinic directly)

Restorative & Surgical Consultations
£65.00 (additional costs for radiographs or diagnostics are not included)

Cosmetic and Orthodontic Consultations
£65.00

Periodontal Consultations
£110.00 (this is purely diagnostic and no treatment will be carried out on the day)

Endodontic Consultations
£110.00 (this is purely diagnostic and no treatment will be carried out on the day)

PanOral Radiograph
£40.00 (can be printed onto CD or emailed upon request)

Cone Beam CT scan
from £120.00-£150.00 (DICOM files can be emailed upon request)

REFER YOUR PATIENT

REFERRING PROVIDERS DETAILS