Refer a patient

Fields marked with an * are required

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Referring practitioner details

Full name *

Practice name *

Phone *

Email *

Address *

Town / City *

Postcode *

Country *

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Patient details

First Name *

Last Name *

Date of birth *

Phone *

Email *

Address *

Address line 2

Town / City *

Postcode *

Country *

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Required treatment

Please tick all that apply

Conservative Treatment
Oral Surgery
Intravenous Sedation
OPG / CBCT Scans
Other

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Referral information *

Medical history

Please attach relevant case files (patient notes, x-rays etc.) allowed file types: png, jpg, gif, webp, pdf, doc, xls, odt, ppt, pptx,

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Anti-spam question *

GDPR consent *

I confirm I have the requisite authority to share the patient's information in connection with this referral.

Refer a patient

We are committed to ensuring that our patients receive high-quality clinical care and excellent customer service.

We will only treat patients solely for the treatment for which they have been referred. We will never undertake any further work without your consent and we will always refer your patient back to you for their continuing care.

0191 265 5467 Book Online

Referring practitioner details

Patient details

Required treatment

Heaton Dental Clinic

More Information

Address

Opening hours

Find out how we can help transform your smile. Call us today on0191 265 5467

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Referring practitioner details

Patient details

Required treatment

Heaton Dental Clinic

More Information

Address

Opening hours

Find out how we can help transform your smile. Call us today on0191 265 5467