Dental Referrals Harlow & Bush Fair

Patient details

First name*

Last name*

Email address*

Telephone number

Date of birth (dd/mm/yy)

NHS number (if known)

Address (including postcode)

Name & address of GP practice (if known)

Referral details

Please select a type of treatment to be referred

Reason for referral

Medical history

Dental history

Other notes or relevant information

Upload any supporting radiographs/images/documents Select supporting uploads (Max 5MB)Upload

Select supporting uploads (Max 5MB)Upload

Referrer details

First name*

Last name*

Email address*

Telephone number

Position/Job title

GDC number (if registered)

Practice name & address (including postcode)

The patient has given valid, informed consent to be referred to Keats House Dental Surgery and gives us permission to contact them regarding their referral, using the details provided.

Yes

The patient understands that all associated costs are to be paid in full to Keats House Dental Surgery and charges may be taken in advance, in order to secure an appointment.

Yes

By submitting this referral, I authorise Keats House Dental Surgery to carry out the above requested service on my behalf.

Yes

By clicking ‘submit referral’, you agree to Keats House Dental Surgery collecting your personal data. To learn more about how Keats House Dental Surgery collects, uses, shares and protects your personal data, please read our privacy policy.

Referrals

Refer your patient for our high standards of dental care

Our referral process

Visit

Contact