Dentist in Cumbria

For Dental Professionals

Online Patient Referral

Ready to Refer?

Simply fill in the secure online referral form and we will handle the rest. We will contact your patient, arrange their consultation, and keep you fully updated throughout.

Where possible please send radiographs and pictures. The more information we have the easier it is for us to assess your patient.

Got a quick question before submitting? Just give us a call, we are always happy to help.

Referring Practitioners Details:

Date of Referral

Practice Name

Practice Address

Practice Telephone

Practice Email

Dentist Full Name

How would you like to be updated about this referral?

Phone Email Post

Patient Details:

Patient Title

Patient Full Name

Patient Full Address

Date of Birth

Patient Phone Number

Patient Email

Medical History

How would your patient prefer to be contacted?

Phone Email Post

Required Speciality:

Referral Information

Scope of treatment (if applicable)

Only treat referred tooth Please treat all teeth you feel appropriate

Clinical Images:

To avoid unnecessary radiographic exposure , we require recent radiographs showing all the teeth in question. You can upload up to 5 images of up to 4mb each in the following formats , jpg, jpeg, png, pdf.

File Upload:

If you wish to upload more than 5 files to support your referral , please email to referrals@ghyllmountdental.co.uk

Consent and communication:

Acceptance

By submitting this form, we will securely collect your details and the patient's details. We will then store and process this information in accordance with our Privacy Policy. I understand and agree to the processing of my personal data as the referring Clinician*

Acceptance

I have made my patient aware of this referral and the provision of their data for this purpose

General Dentistry

Cosmetic Dentistry

Facial Aesthetics

Dental Referrals

Orthodontics

Endodontics

Oral Surgery

Sedation

Periodontics

Restorative

Patient Self Referrals

Dentist in Cumbria

For Dental Professionals

Online Patient Referral

Ready to Refer?