Patient referral

Our Referral Policy:

We will only carry out treatment in accordance with instructions from the referring dentist.
No further treatment will be carried out without authorisation from the referring dentist.
The patient will receive a detailed treatment plan and all costs will be discussed before treatment.
We will keep you updated throughout the treatment.
We aim to send a full treatment report to the referring dentist within two working days.

Please use the form below to refer a patient

Referring Clinician Contact Details

Clinician Name

First Name

Last Name

Clinician Email

Clinician Practice Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Practice Telephone

Clinician Mobile Phone

Patient Contact Details

Patient Name

First Name

Last Name

Patient D.O.B

YYYY

Patient Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Telephone

Patient Email Address

Referral Details

Treatment required

Brief description of request

PerioClinic at Gants Hill 128 Woodford Avenue Gants Hill, Essex, IG2 6XA

To Call Us

📞

020 8551 9336

info@perioclinic.co.uk

Member of

For Clinician - Patient referral form

Patient referral

Our Referral Policy:

We will only carry out treatment in accordance with instructions from the referring dentist.

No further treatment will be carried out without authorisation from the referring dentist.

The patient will receive a detailed treatment plan and all costs will be discussed before treatment.

We will keep you updated throughout the treatment.

We aim to send a full treatment report to the referring dentist within two working days.

Perio Clinic

PerioClinic at Gants Hill 128 Woodford Avenue Gants Hill, Essex, IG2 6XA

To Call Us

020 8551 9336

info@perioclinic.co.uk

Member of