TLC Dental | Private Dentist & Dental Practice

t: 01625 878 505

At tlc dental we take on referrals for sedation, oral surgery and implant dentistry, to refer a patient please compete our Referral Form below.

tlc dental welcome referrals

OUR REFERRAL FORM

Patient Name

Patient Date of Birth (DD/MM/YYYY)

Patient Address

Patient Phone Number

Date of Referral (DD/MM/YYYY)

Dentist Name

Name of Dental Practice

Dentist Address

Dentist Phone Number

Dentist Email

Type of Referral

IV Sedation Implant(s) Oral Surgery

Case Information

Additional Case Information

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patient details

dentist

details

Please summarise the case and relevant medical/dental history.

E.g. X-Rays, Patient Notes

11 Chester Road

Poynton

Stockport

SK12 1EU

t: 01625 878 505

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