Dental Referrals - The Dental Sanctuary

Treatment Referral Form

Referring Dentist

name of practitioner*

practice name*

practice Address*

practitioner email Address*

practitioner contact number*

Patient Details

patient name*

patient Address*

patient date of birth*

patient email Address*

patient contact number*

referral for*

other information

is the treatment urgent?*

purpose of referral

patient's complaint

Patient History

please provide a brief patient history below*

Other Relevant Information

would you like to carry out any treatment yourself?

would you like to add any more information?

submitted by*

date of submission*

*Our Treatment Coordinator will be in touch with you soon for further information relevant to this referral.

i consent to submitting and having my data stored; as well as being contacted in response to this form*.

Thank you! Your enquiry has been received! We'll be in touch with you as soon as possible. If you don't hear back from us within 2-3 business days, please email us at reception@thedentalsanctuary.co.uk.

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How can we help?

You can find answers to some common questions under our FAQs. If you’d like to get in touch with us, please fill in our enquiry form; alternatively, please feel free to email or call us and a member of our team will be happy to assist you.

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book an appointment

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call us: 0161 660 3027

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Make a dental referral with The Dental Sanctuary

Treatment Referral Form

Referring Dentist

Patient Details

Patient History

Other Relevant Information