Dentist Referrals

Simply fill in the referral form opposite and our friendly Treatment Coordinator, Laura, will be in touch with your private patient to arrange a consultation for them. Alternatively, your patient can call 01695 581212 between 8am and 4.30pm, Monday to Friday and speak to Laura directly, or fill in our easy self-referral form themselves.

For your NHS patients, please ensure that they will not have turned 18 before their treatment commences (for waiting times, please contact the practice on 01695 581212).

*Required fields

Referral form

Referral type: NHS/Private	NHS Private
Patient Details
*Full name:
Title
*Sex	Male Female
*DOB
Parent's full name (if under 18)
*Contact telephone number
Other telephone number
*Email address
*Home address
*Postcode
Dentist details
*Referring dentist, full name
*Dental practice
*Contact number
Email address:
Any other information :

55 Burscough Street, Ormskirk, Lancashire L39 2EL Tel: 01695 581212 Fax: 01695 581030

Dentist Referrals

Referral form

Referral type: NHS/Private

Patient Details

Dentist details