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 wynyard@burgesshyder.co.uk

Patient Details

* Indicates required field

Patient's Title *

Patient's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Patient's DoB

Patient's Gender *

Patient's Email *

Patient's Mobile Number

Patient's Home Phone Number

Patient's Consent

Patient's Consent Received for Sending Details

Referring Practitioner

Practitioner's Name *

First

Last

Practitioner's GDC Number *

Practitioner's Phone Number *

Practitioner's Email* *

Referring Practice *

Practice Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Referral Details

Reason for Referral *

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

Click or drag files to this area to upload. You can upload up to 10 files.

Accepted file types: jpg, pdf, png. Max. file size: 64 MB, Max. files: 10

GDPR consent *

By submitting the above information, you are confirming that you have read and agree to the Privacy Policy and that you consent to us contacting you by phone or e-mail regarding your referral.

Cookie	Duration	Description
cookielawinfo-checkbox-analytics	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checkbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-others	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-performance	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.