Refer online

Refer a patient to Guildford Dental Centre by completing the form below.

"I agree to use the referral criteria below; that evidence of adequate training has been provided for each of the people named above appropriate to their IRMER17 roles; that adequate information will accompany each referred patient to allow the justification process to proceed, as set out in the standard imaging referral form attached.

I understand and accept that it is my responsibility to report on the radiograph"

Patient title *

Patient first name *

Patient surname *

Patient date of birth *

Patient contact telephone *

Patient contact email

Patient address and postcode *

Type of Referral *

Periodontics Implants Endodontics Orthodontics Sedation CBCT Scan OPG

Please tell us about your referral *

For CBCT and OPG referrals please ensure you have included justification

How many radiographs or other images do you want to upload? *

File 1:
Upload File

File 2:
Upload File

File 3:
Upload File

File 4:
Upload File

Referring dentist title *

Referring dentist name *

Referring dentist contact email *

Referring dentist contact telephone *

Referring dentist job title *

Referring dentist GDC number *

Referring practice name *

Referring practice address and postcode *

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