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Referrals

Contact

19 Oakleigh Road North, London, N20 9HE

NHS and Private Dentistry

Referrals

We welcome referrals for a range of private dental treatments. These include dental implants, periodontics and orthodontics.

Practice Details

Referring Practitioner*

Practice Name*

Practitioner Email*

Practice Address

Practice Telephone Number *

Date Referred

Patient Details

Patients Name

Patient Address

Patient Date of Birth

Patient Home Telephone Number

Patient Work Telephone Number

Patient Mobile Telephone Number

Reason for Referral

Dental Implants
Periodontics
Orthodontics

Dental Implants

Diagnosis and treatment planning
Implant placement
Implant restoration
Treatment of peri-implantitis
Other

Periodontics

Diagnosis and treatment planning
Surgical and non-surgical management of periodontal disease
Crown lengthening
Grafting and aesthetic contouring
Other

Orthodontics

Diagnosis and treatment planning
Invisalign/clear aligner
Lingual orthodontics
Other orthodontics
Interceptive device (to stop thumb sucking)

Observations / Comments

Comments

Attach radiograph file if available:
Please attach file as a jpeg, file size no greater than 3MB

required fields marked *

Please note - this referral form should only be used for transferring information of a non-sensitive nature. If you wish to provide us with medical information or other potentially sensitive data, please contact us by telephone on 020 8445 6353 and we will advise.
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Would you like to book an appointment? Please call us today on 020 8445 6353