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

Dentist details

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!

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