Clinic Open

Dentist Referral

Use the form below to refer for Dental Implants, CBCT Scan, Minor Oral Surgery & IV Sedation

SELECT REFERRAL OPTION (Hold CTL to select multiple options)

Referral Option

REFERRING DENTIST DETAILS

Dentist First Name

Dentist Surname

GDC Number

Dentist Phone Number

Dentist Email

Practice Name

Practice Address

Practice Postcode

PATIENT DETAILS

Patient's First Name

Patient's Surname

Patient's Date of Birth

Patient's Phone Number

Patient's Address

Patient's Postcode

Proposed Treatment Plan

File Upload

(Upload any radiographs and / or photographs related to the proposed treatment plan.)

Consent

I consent to my personal data being collected and stored as per the Privacy Policy.

Consent2

I have informed the patient that this is a private referral only.

How to Find Us

Ilford Dental Care

Work Time

Mon-Fri: 9AM - 6PM Sat: 9AM - 1PM Sun: CLOSED

Contact Us

1Enquiry

2Your Personal Details

3More info

4Submit

Are you currently registered with Ilford Dental Care *

Yes
No
I am not sure

Message

ILFORD DENTAL CARE LTD trading as Ilford Dental Care with its registered address at 180 Thorold Road, IG1 4HA, Ilford, United Kingdom is authorised and regulated by the Financial Conduct Authority and entered on the Financial Services Register, reference number 935663.