Refer a patient

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• Referring a dental patient

  Give your clients the solutions they deserve when you need to refer them for specific dental treatments. Our referral service is available for dentists throughout Cheltenham, Cirencester and Gloucestershire. From sophisticated computer driven dental technology to an in-house laboratory, Cheltenham Spa Dental & Implant Clinic has some of the best technology available.

  We are currently accepting referrals for:

  • Bone Grafting
  • Panoramic X-Rays
  • Cone Beam CT scan
  • Same Day Teeth
  • Sedation Clinic

Make a referral

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:

Next stage

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:

Next stage

Referral Details (step 3)

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Enter the name of the relevant clinician to refer your patient to (if known)

Please select... Dr Sarah Duggan Dr Chris Hugh

Treatment required *

Please select... Cosmetic dentistry Dental crowns Dental veneers Dental implants All-on-4 Implant secured dentures Multiple dental implants Same day teeth Single dental implants Other treatments Smile in a day Teeth straightening Clear aligners Invisalign

Observations & Dental History

General assessment of dental health

Oral hygiene *

Poor Fair Good Other

Teeth of poor prognosis *

Relevant medical history *

Additional files
- 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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Any comments

Confirmation

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

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

Finish

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Submit

If you would like to personally discuss the case you wish to refer with one of our dentists or specialists, please request a call back, stating the best time to call with a preferred number, or email your enquiry to reception.cheltenhamdentalspa@portmandental.co.uk.

We guarantee everything you share with us remains in the strictest confidence at all times.