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Referrals
Referral form

Make a referral

To refer a patient to Walker & Associates Dental & Implant Clinic, simply complete and submit the below referral form.

Please include all relevant clinical information regarding this case, and remember to attached any x-rays if relevant.

After reviewing, we will contact the patient to introduce ourselves and book them in. We will also keep you fully updated on progress throughout.

Patient details (step 1)

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First name *

Last name *

Address 1 *

Address 2 *

Postcode *

Date of birth *

Contact number *

Email *

Please check that the following fields have been filled out correctly:

Referring Dentist Details (step 2)

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First name *

Last name *

Phone number *

Practice name *

Practice address line 1 *

Practice address line 2

Practice city *

Practice county *

Practice postcode *

Email address *

Please check that the following fields have been filled out correctly:

Referral Details (step 3)

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Enter the name of the relevant clinician to refer your patient to (if known)

Treatment required *

Reason for referral/treatment required. Please detail relevant dental history and preferred clinician if applicable

General assessment of dental health

Oral hygiene *

Poor Fair Good Other

Teeth of poor prognosis *

Relevant medical history *

Additional files
- Please note that only the following file types are supported: jpeg, jpg, png, gif, pdf, doc, docx, xls, xlsx, rtf, ppt, odt.

Other records sent via post

Radiographs Study models Diagnostic wax up None Other

Final restoration to be placed by:

The Referring Dentist By Walker & Associates Dental & Implant Clinic

Any comments

Confirmation

I confirm I have the requisite authority to share the patient's information in connection with this referral

Please check that the following fields have been filled out correctly:

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Walker & Associates Dental & Implant Clinic is a trading name of Gloucester House Dental Practice Limited. Registered in England and Wales: 05952323. Registered Office: Rosehill, New Barn Lane, Cheltenham, Glos GL52 3LZ. Gloucester House Dental Practice Limited is an appointed representative of Portman Healthcare Ltd, who is authorised and regulated by the Financial Conduct Authority as a credit broker under registration number 700090. Portman Healthcare Ltd also trades as Portman Dental Care. Registered in England & Wales: 06740579. Registered office: Rosehill, New Barn Lane, Cheltenham, Glos GL52 3LZ. Credit is subject to status and affordability, and is provided by Novuna Personal Finance a trading style of Mitsubishi HC Capital UK PLC. Terms & conditions apply. Portman Healthcare Limited is the controller of your data and registered with the Information Commissioners Office under registration number Z1929449

*Walker & Associates Dental & Implant Clinic is offering new private patients who have not previously registered with the practice a new patient examination for £119 including x-rays. New patient examinations include assessment of teeth, any existing restorations, gum health and soft tissue. Offer also includes two bitewing x-rays, one for each side of the mouth. Any additional x-rays deemed necessary by the clinician will be chargeable, and any recommended treatment required will be estimated for the patient as an additional cost. Walker & Associates Dental & Implant Clinic reserve the right to change or withdraw this offer at any time. This offer is non-exchangeable, non-transferrable and is not redeemable for cash or other treatments. Offer ends 31.12.24.

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Last updated 11/12/2020 at 12:50

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