Dental Referrals

We are an advanced dental referral centre serving Stourbridge and surround towns and villages across the West Midlands, providing cosmetic, orthodontic and advanced dentistry. All our dental referrals are easy and straightforward, patients can contact us directly or with a referral from their existing dentist.

We accept referrals from dentists, dental therapists/hygienists and clinical dental technicians. Please fill in the online form below or call us.

Dentist referred patients won’t be eligible to become regular patients of ours, and they are always returned back to their referring dentist .

PRACTICE DETAILS

Referring Dentist Name *

Practice Name *

Practice Postcode *

Practice Phone Number *

Practice Email *

PATIENT DETAILS

Patient Name *

Patient Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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Patient Date of Birth *

Patient Phone No. *

Patient Email *

Treatment Required *

• Restorative Dental Work
• Orthondontic
• Implants
• CBDT 3 D Scan
• Cosmetic Dental work
• Endontics
• Surgical Extraction
• Treatment Under Sedation
• Other - Please fill out details below

Any Additional Treatment Information

Is this Treatment Urgent?

• Yes its Urgent - Patient in Pain
• Yes its Urgent - Not in Pain
• Not Urgent

Has the patient been made aware of costs of the procedures before treatment *

• Yes
• No

Optional File Upload Patient Details

Click or drag files to this area to upload. You can upload up to 4 files.

Please upload above the patient's Records / Radiographs. (as per GDC guidelines, we aim to keep patients' radiation to a minimum. Therefore, we will be grateful if you could provide us with relevant, existing X-rays).

Submit