Referral Form

We treat private patients of all ages from school children to retired professionals. Patients are never too old for orthodontic treatment and it can greatly improve their quality of life and confidence.

Please use the form below to refer your patient details to our practice. If you are a patient wishing to refer yourself for private treatment please use this form also.

Fill in all the required fields and should you have further information that will aid treatment please fill in the 'Additional Information' box.

Patient Details

Patient's Name: *

Patient's Date of Birth: *

Patient's Address:

Patient's Post Code:

Patient's Contact Number:

Patient's Email Address:

Does the patient have any siblings already under treatment with us?

Reason for referral:

Dentist details

Dentist's Name *:

Practice Name:

Practice Address:

Practice Post Code:

Practice Contact Number:

Practice Email Address *:

Additional information

Upload X-ray/opg scans

Get in touch

Leave more information and we’ll be in touch soon!

Interest Free Finance

Spread the cost and budget for the treatment you have always wanted! At last! An affordable and easy way to pay for the treatment you want. when you want, on a repayment plan to suit your circumstances.
No up-front deposit – with no initial financial outlay, you avoid dipping into your savings or having to find a lump sum to start your treatment.
Wider choice of treatments – by making treatment more affordable, you can access a fuller range of treatments and choose the one perfect for you.
Finally a great looking Smile!

Find out more »

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