To refer a patient to Victoria Road Practice, simply complete the form below. Once we have reviewed the details we will contact the patient and book them in. We will also keep you fully updated on progress throughout.

More details of our referrals can be found here on our online booklet: Open Booklet

Referring dentist details

Practice name *

Dentist name *

Contact number *

Email *

GDC number *

Patient details

Title *
—Please choose an option—Mrs.Ms.MissMr.Master

Full name *

Date of birth *

Telephone number *

Email

Address *

Postcode *

Previous treatments

Has the patient had any treatment with us before? *
—Please choose an option—YesNoUnsure

Treatment

Treatment(s) required *
Endodontic TreatmentOrthodontics (Clear Aligners)ImplantsImplants under sedationOral SurgeryFacial RejuvenationOPGCBCTCBCT (with report)Oral surgery under sedation

Is the patient nervous? *
—Please choose an option—YesNo

Medical history

Please enter as much detail as possible

Any allergies? *
—Please choose an option—YesNo

If yes, please detail the allergies

Details of referral

Please ensure that you include as much detail as possible including radiographs (where applicable).

If you are referring your patient for OPG or CBCT, please note that we require a justification for exposure.

Comments/details

Maximum file upload size 4MB (per attachment).

Any X-rays or relevant attachments

Additional X-rays or relevant attachments

Additional X-rays or relevant attachments

Additional X-rays or relevant attachments