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Self Referrals

From 2015, patients between the age of 10-16 years can only be referred under the NHS by your General Dentist.

Alternatively you can self refer, however your consultation will be on a private basis. Please refer to the ‘Fees and Finance’ section for consultation fees.

To self refer simply complete the form and the reception team will contact you to discuss your needs and make that first appointment for you.

Alternatively, you can call 01372 749 040 between 8am & 5pm Monday to Thursday, 8am to 1pm Friday and ask for an appointment.

Your Full Name (required)

Your Email


DOB (required)

Contact Telephone (required)

Other Telephone

Home Address (required)

Postcode (required)

Your dentists name

Practice Name & Address

How did you find us?

Any other information