Referrals – Victoria Road Implant & Dental Clinic

Dentist Referrals

To refer a patient to us please fill out the form below. Radiographs and photographs may be added to the online form, but are not essential. If you would like a patient to be seen by a specific clinician, please add their name in the ‘Reason for Referral’ box.

General Enquiries

Name

Dental Practice Making Referral

Practice Contact Number

Email

Dental Speciality (optional)

Dental Implants

Endodontics

Teeth Straightening/Aligners

Complex Restorative

CBCT Scan with or without reporting

OPG

Surgical Extraction

Sinus Lift

Tooth/Teeth Referred

Patient's Name

Patient's Email Address (optional)

Patients DOB

Patient's Phone Number

Relevant Medical History (e.g., allergies, medical conditions, medications):

Relevant Clinical Findings/Radiographic Findings/Previous Treatment/Additional Notes or Requests

Patient X-Rays (optional)

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Consent to Share Information:

• I understand that by submitting this form, I am providing my patient's information to [Your Practice Name] for the purpose of a dental referral. I have obtained the patient's consent to share this information.

Yes

Victoria Road Dental & Implant Clinic Referral Charter

We understand the sensitive nature of referring patients for the more complex aspects of modern dentistry. Our team are here to support you wherever possible.

Outline Fees - Subject To Quotation Depending Upon Complexity.

Standard Referral Fee: £90
Dental Implants: £2,750
Endodontics: £675

OPG: £135

CBCT: 225

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Dentist Referrals

Victoria Road Dental & Implant Clinic Referral Charter

Outline Fees - Subject To Quotation Depending Upon Complexity.