Dental Referral to our practice

This referral page is prepared to serve Dentists who wish to refer dental patients to us. For the purpose of data protection, we need our professional colleagues to use our secured form to send us the patient’s details. Alternatively, you can download a PDF version of the form, fill it out, and send it to us.

Download PDF Here
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Complex Treatment Dental Referrals

Thank you for choosing to refer your patients to our dental practice; we appreciate your trust in our dental practice. To make sure your referrals are safe and secure, we have an optimized and secure online referral form. This form is designed to safeguard sensitive patient information and maintain the utmost confidentiality throughout the referral process. We are committed to giving the best care to our patients and building strong relationships with referring dentists like you.

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Practitioner’s information
2
Patient’s information
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Last Page

Referral Practioner Details

First Name *
Last Name *
Practice Name *
Practice Address *
Email *
Phone Number *
Postcode *

Patient Details

Patient’s Fullname *
Phone Number *
Patient’s Email
Patient’s date of birth *
Patient’s Home Address *
Relevant Medical History
Please use n/a if not applicable
Additional Info
Please use n/a if not applicable
Reason for Referring *
teeth chart
Please indicate which tooth/teeth requiring treatment *
Please use n/a if not applicable
Upload X-ray
Maximum file size: 20 MB and must be jpeg of png format
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Privacy Agreement *

Download The Referral Form in PDF Format

LONGWOOD_DENTAL_REFERRAL_FORM_2024-webDownload