Refer A Patient

We are happy to accept patient referrals for:

Root Canal Treatment with our Endodontist
Dental Implants
Invisalign
Composite Bonding
Cosmetic Treatment
Treatment of toothwear
Complex dental extractions

Please complete the form below to send a referral to us.

Here at Pitshanger Dental Care we accept many types of referrals from other dentists, such as endodontics, hygienist, dental implants and much more. Most of the treatments and fees we offer are found on our treatments page. If you have any queries about referring a patient to us, please just use our contact form to email us or give us a call and we will do our best to assist you.

Referral Form

Referring Dentist Details

Name

Contact Number

Please Provide Your Dental Practice Address

Patient Details

First Name

Last Name

Date of Birth

Patient Gender

Male

Female

Other

Contact Number

Please Provide Patients Address

Reason for Referral

Please Specify the Tooth/Teeth to be Treated

Please provide further information relating to the referral including the patients concerns.

Please provide any relevant dental history

Medical history

Please Upload any relevant Photos and Radiographs

Upload File

Form Completed By:

I confirm that the patient is aware that a referral has been made is happy for us to contact them and store their details(see privacy policy)

Thank You for submitting your referral. A member of our team will be in touch

Pitshanger
Dental

020 8997 3012

pitshangerdental@gmail.com

Refer A Patient

Referral Form

Referring Dentist Details

Patient Details

Reason for Referral