Make a referral

Our highly skilled clinicians have been seeing referred patients for many years and we are experienced at managing these relationships, so you can rest assured that we will only treat your patients with the same high standards as you would.

Our experienced clinicians here at Durham Smile Clinic accept referrals in the following:

Need to confirm other treatments

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 *

Observations & Dental History

General assessment of dental health

Oral hygiene *

Poor Fair Good Other

Teeth of poor prognosis *

Relevant medical history *

Additional files
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Confirmation

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

Working in partnership with our referring dentists

Make a referral

Patient details (step 1)

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

Referring Dentist Details (step 2)

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

Referral Details (step 3)

General assessment of dental health

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

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