Please note: For first time referrals please complete the SLA linked below and attach it to your referral form. This only needs to be completed once for each practice and referring dentist unless any changes are made.

Referrer Details

Dentist Name

GDC Number

Practice Name & Address

Telephone Number

Email Address

Patient Title

Patient Name

Patient Address

Date of Birth

Phone Number

Email Address

Relevant Medical History (Include conditions, medications, allergies)

Upload File

If individual tooth please indicate:

Justification

Additional information (optional)

Payment:

Patient to pay

Practice to pay

For those who have already submitted an SLA previously:

Tick to confirm your current SLA agreement is correct

Thanks for sending your referral! We will be in touch soon