Dental Referral System

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Home
About
Treatments
Skin Clinique
Dental Plan
Reviews
Referral
Media
Our Clinics
Gift Cards

Live booking

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Live booking

Please use this portal to refer your patients to us. Note, this system is fully encrypted using 256 bit SSL.

Referring Dentist Details

Referring Dentist Details

Practice Name *

Dentist name *

Your contact number *

Email *

Email confirmation *

Patient Details

Patient Details

Title *

Name *

Date of birth *

Telephone number *

Email *

Email Confirmation *

Address *

Postal code *

Has the patient been referred before? *

No
Yes

Treatment Requested *

Periodontics
Prosthodontics
Endodontics
Implants
OPG
Oral Medicine
Facial Rejuvenation
Orthodontics
Oral Surgery
CT Scan
Sedation
Other

Other - Treatment Requested

Is there any relevant case history? *

No
Yes

Relevant medical and dental history

Any X-rays enclosed?

File name:

File size:

Additional X-rays #2

File name:

File size:

Additional X-rays #3

File name:

File size:

Additional X-rays #4

File name:

File size:

Validate Email

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Brentford
Chiswick
Harley Street
Lewisham
Whitstable

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All rights reserved.

Our Clinics

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Memberships

Current Offer For Patient Who Hold Banning Dental Group And Skin Clinique Premium Membership Card:

1 Complimentary dentist visit
1 Complimentary hygienist visit
7% reduction on:
- any crowns, bridges and dentures and
- any other dental work (excluding specialist treatment)
- other dental work
- any additional hygiene treatment