We accept referrals from dentists, dental therapists, hygienists and dental technicians.

Individuals seeking treatment are also welcome to contact us directly, or ask their current dentist for a referral.

If you wish to make a referral simply complete the form using the Referral Form for Dentists, or Referral Form for Patients.

referral-badge

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Refer a Patient

Please fill out the form and we will be in touch

    REFERRING DENTIST DETAILS

    Name of Referring Dentist*

    Practice Name*

    Practice Address*

    Contact Telephone No.*

    Your Email*

     

    PATIENT DETAILS

    Patient Name*

    Patient Address*

    Date of Birth*

    Home Telephone No.*

    Mobile No.*

    Patient Email*

    GP Name*

    GP Practice*

    GP Practice Address*

    Does your patient consent to this referral and the submission of their details*

     

    Referral Details

    Type of referral*

    Please provide relevant medication history

    Reason for referral

    Additional information

    Upload a file

    Please obtain patient consent before submitting this referral.

    Refer a Yourself

    Please fill out the form and we will be in touch

      YOUR DETAILS

      Your Title*

      Your Name*

      Your Surname*

      Home Telephone No.*

      Mobile No.*

      Your Email*

       

      REFERRAL DETAILS

      Type of Referral*

      What is your reason for referral*

      Please upload any relevant case files

      Please obtain patient consent before submitting this referral.

      Contact us

      Please send us any questions and we'll get back to you.