Thank you for referring your patient to Orchid Dental and Implants.
We are committed to providing high-quality specialist care and will return your patient to your practice following completion of treatment.

Referring Practice Details

Practice Name

Referring Dentist

GDC Number

Address

Practice Address

Telephone *

Email *

Patient Details

Full Name *

Date of birth

Patient Address

Patient Telephone *

Patient Email

Treatment Required (please tick)

Complex Root Canal Treatments

Periodontology

Composite Bonding

Cone Beam Computed Tomography (CBCT) Scan

Clinical Information

Tooth/Area concerned:
Relevant clinical details:
Medical History considerations:

Is the patient aware of this referral?

Yes

Radiographs / Files

Sent with patient

Sent by email

To follow

Additional Notes

Orchid Dental and Implants
Unit 4, Bower Shopping Complex, Pollard Road, Bridgwater TA6 4YA
01278-327-259
[email protected]

Our treatment coordinator will contact your patient promptly to arrange an appointment.