REFERRAL FORM

High Street Smiles are pleased to offer a referral service should the need arise. We understand that it is not always easy to hand your patient to another dentist and feel 100% confident, However we promise that we will take the best possible care of your patient as we do with our own before returning them to your care. All referred patients will always be discharged back to your care. We do not have the facilities nor manpower to provide general dentistry on a continuing basis.

 

    Referring Dentist

    Name/Practice:

    Address:

    Telephone Number:



    E-mail:

    Date of Referral




    Patient Dr/Mr/Mrs/Miss

    Name:

    Address:

    Telephone/Mobile:



    E-mail:

    DOB:




    Requirements

    Please Choose:

    I wish to restore the impants :



    Short Summary of Case:

    Referring to


    clear submit


     

 

Inman Alighner
 Whitening
Six Month Smiles

FINANCE Options Available

High Street Smiles are now pleased to offer dental finance.

Click here for details
.

Chrysalis Finance Approved Surgery