Private Patient Referrals to Waterside Dental Health

This form is for the convenience of dentists who wish to refer patients to one of our team members for specialist treatment

Please inform your patient that we ask for a deposit (except for free consultations) that is transferable with 48hrs notice for all of our appointments. The deposit is then deducted from the cost of the treatment.

Enter your referral details below. Digital X-rays and photographs can be emailed to referrals@watersidedentalhealth.co.uk. Please ensure that any images sent have the patient's name in the filename.

Any difficulties or questions, please phone or email.

1) Complete the online form (below). This is the preferred method for making referrals
2) At the end you will be asked to confirm the data on the form before it is finally sent
3) If at any time you wish to stop filling the online form, scroll down to the bottom to cancel

Private Referrals to Waterside Dental Health

* - required


	Patient Details

*I am referring the patient for:

Hold down Ctrl key to select more than one.If you select 'Other' please put details below.

*Name:

*Patient's DOB
(dd/mm/yyyy):

*Patient's preferred
phone number:

Patient's
alternative phone
number:

Patient's email:


	Referring Dentist's Details

*Your name:

*Your phone:

Your email:

*Your practice name and address:

(chars left: 500)

*Detailed reason for referral:

(chars left: 3000)

*Urgent?

No
Yes

Upload 1:

Make sure the patient's name is in the file name. If you need to send more than three x-rays or photos, save them together in a zip file or email them.

Upload 2:

Upload 3:

*Referral Date:

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