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Dental Referral Form

Patient referrals

Referring practitioners can use the form below to send all relevant information to us securely.

A number of the form fields are compulsory in order to refer a patient.

The following services are accessed via appointment only following referral from a medical doctor or dental practitioner:

Oral Surgery Referral

Patient Details

Patient name:*
Date of birth:*
Home phone:
Mobile phone:
Patient Email:

Referring Dentist Details

Referring dentist:*
Email address:*
Dental surgery name:*
Surgery Address:*

Referring Treatment Details

Please help us to understand the patients needs, Kindly explain each tooth / all teeth affected.


Additional Treatment Details

Please select the main reason for referral. You can select multiple options if required.
Where possible please add your any additional comments below.

Reason for referral:*

In this section, kindly upload any relevant Radiographs or associated files for review.

Upload radiographs:*
Additional uploads:

Word Verification:
Date of birth:(1)*

About Us

Bromsgrove Dental Clinic is supported by a friendly reception and top notch dentists & a wealth of excellent dental treatments along with our reassurance & peace of mind.

Victoria Sutton

Reception Manager

Address : 1A Highfield Rd,
Bromsgrove, Worcester
B61 7BD, UK

Phone: 01527 874 537


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