Make a referral

For clinicians wishing to refer their patients to us (patients wishing to book a consultation for themselves should do so via the Book a Consultation link)

Patient Details

Prefix

First Name *

Last Name *

Street Address

Apartment, suite, etc

City

Postcode

Phone Number *

Email Address *

Date of Birth

Day

Month

Year

Additional notes0 / 180

Referring Practitioner

Dentist's Phone Number *

Dentist's Name *

GDC Number *

Practice Name *

Practice Email *

Street Address

Apartment, suite, etc

City

County

Postcode

Select Treatments *Implant surgeryAdvanced Endodontic treatmentAesthetic and advanced restorative treatmentSuresmile AlignersMinor Oral SurgeryAdvanced Periodontal ServicesRadiography (CBCT / OPG)General Dentistry / Other Referral

SedationInhalation Sedation (Nitrous Oxide)

Sedation Criteria

In order for us to provide the most appropriate treatment for your patients please refer to our Sedation Criteria

Relevant Medical History

Referring dentist's comments

File Attachments (radiographs, photographs etc)

Drag and Drop (or) Choose Files

Consent *

Yes, I agree with the privacy policy.

Pearls Dental Practice, 5-7 Willow Street, Oswestry, Shropshire SY11 1AF. Telephone 01691 658114. Kalisetty Dental Limited trading as Pearls Dental Practice is a credit broker not a lender. Registered in England & Wales 13088809 Registered Address: 5-7 Willow Street, Oswestry, Shropshire SY11 1AF

GET IN TOUCH

Phone

01691 658114

Email

[email protected]

Address

5-7 Willow Street
Oswestry
SY11 1AF
UK