Refer a Patient

We will contact the patient to introduce ourselves and book them in. You will be kept fully updated on your patient’s progress throughout.

Referral Form

Date of referral

Referrer Details

Referring dentist's name

GDC number

Practice name

Address

Address Line 1

Address Line 2

City

Post Code

Email

Practice phone number

Referring dentist's mobile (optional)

Patient Details

Title

First Name

Last Name

Daytime phone

Mobile

Email

Patient address

Address

Street address

Address Line 2

City

Post Code

Date of Birth

Relevant medical history

Please include all relevant clinical information and remember to attached any x-rays if relevant.

I certify that the information provided on this referral form is accurate to the best of my knowledge, and that the patient has consented to onward referral for the provision of specialist treatment/services from Impressions Dental Care*

I confirm that the patient has given consent to be contacted by Impressions Dental Care*

Referring dentist's signature

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Call now

Impressions Dental Care
0115 938 2577

What we do

Check out our other services

Where we are

Grange Villa, 20 Thorne Road, Doncaster, DN1 2HS

01302 361 150