Make a referral

To refer a patient to No. 65 Dental & Implant Clinic, simply complete and submit the below referral form.

Please include all relevant clinical information regarding this case, and remember to attached any x-rays if relevant.

After reviewing, we will contact the patient to introduce ourselves and book them in. We will also keep you fully updated on progress throughout.

Patient details (step 1)

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

    Referring Dentist Details (step 2)

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

      Referral Details (step 3)

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      General assessment of dental health

      Oral hygiene *

      - Please note that only the following file types are supported: jpeg, jpg, png, gif, pdf, doc, docx, xls, xlsx, rtf, ppt, odt.
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      Confirmation

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

        Portman Dental Care Awards

        Fmc Logo 2019 Winner Oby M25
        Award Logo 2018
        Dental Industry Award - Portman Dental Care
        The Dentistry Awards - Portman Dental Care
        Private Dentistry Awards - Portman Dental Care
        Elite Practice Award - Portman Dental Care

        COVID SECURE - Our practice remains OPEN and welcoming patients. We have introduced several ways to keep you safe, take a look for more information.