01743 231001


implant dentistry


Referral Form

We have tried to make referring to the practice as simple as posssible. You may contact us using the online form below, by telephone, by email or by downloading a hard copy of the form by clicking here.

When we know your requirements Elaine will arrange an appointment at a time to suit your patient.

Should you wish to speak to Richard Gatenby before referring a patient or indeed to discuss any aspects of our care please do not hesitate to phone. If you have any current radiographs of your patient, especially an OPT, it would be most helpful if this could be provided.

You can be confident that your patients will be treated with utmost professionalism, courtesy and consideration and that they will return to your care following the treatment for which they have been referred. Obviously the consultation is the starting point, and if you wish to be present, we can easily accommodate this. Similarly, you are welcome to watch and/or assist in any of the procedures.

Thank you for referring your patient. Please fill out all sections of the form below where possible.

new park house dental centre | brassey road | shrewsbury | SY3 7FA | 01743 231001 | info@implant-dentistry.me.uk

Patient's Details


Full Name

Date of Birth


Phone Number

Mobile Number

eMail address

Dentist's Details

Dentist's Name

Practice Name

Contact Name

Contact Number

eMail address

Procedure required