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Dentists Referral Form

Dentists Referral Form

How to refer

Please fill in and submit the form below. If you have any queries about referring please call us on: 01865 370375

    Treatment Required

    Dental ImplantsEndodonticsOrthodonticsPeriodonticsOPT (£65.00 patient charge)Facial AestheticsCBCT (£150) a separate referral form will be sent to the clinician to fill relevant information upon receipt of ticking this box.
    OPT/CBCT - the prescriber acknowledges Ridentes is not providing and is not responsible for providing any interpretation of images or clinical service such as diagnosis or treatment.
    Our CBCT/OPT scanner is standing. The patient must stay totally still for up to 30 seconds. If the patient is not ambulatory, able to sit unsupported or weight bear, or unable to stay still for the scan please contact us before hand as we may be able to suggest an alternative imaging.

    Private Patient’s details

    Referring GDP details