Dentist Referrals

At Burgess and Hyder Wynyard it is our pleasure to offer your patient treatment. We understand how important trust is when offering your patient the best option for treatment which is why we put communication and care at the heart of everything we do for referred patients. The process is simple, just complete the form below and one of our excellent team members will be in touch to book your patient in at the earliest convenience.

If you have any questions in the mean time please do get in touch with us on 01740 644044 or email us at [email protected]

Patient Details

* Indicates required field

Patient Title *

Patient's Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Patient's Mobile Number *

Patient's Home Phone Number *

Patient's Email *

Patient's DoB *

Patient's Gender *

Patient's Consent Received for Sending Details

Referring Practitioner

Practitioner's Name *

First

Last

Practitioner's GDC Number *

Referring Practice *

Referring Practice Address *

Line 1

Line 2

City

State

Zip Code

Country

Practitioner's Phone Number *

Practitioner's Email *

Referral Details

Reason for Referral *

Dental Implants Oral Surgery

Observations and Dental History *

Please add as much relevant clinical history information as possible.

Medical History *

Please add as much relevant medical history as possible - in particular significant conditions, allergies or medications.

Upload Any Reference Documents *

Max file size: 64MB

Submit