Refer Your Patient

Thank you for referring your patient to Thistle Dental. We will take good care of them and promise to always return your patient to you at the end of their treatment for your continuing care. Our referral system is a simple and effective way to refer your patients to Thistle Dental. Simply complete the form and we will take it from there, keeping you informed at every step along the way.

Pathway

Referral Pathway

Your Name

Dentist Name (Required)

Practice Name (Required)

Practice Address

Address Line 1 (Required)

Address Line 2

Town/City (Required)

County (Required)

Post Code (Required)

Telephone

E-Mail Address

Terms and Conditions

We want you to understand why we need your registration details. Please confirm that you have read the terms and conditions before you continue.

I agree to the referral terms and conditions (Required)

Yes

Patient Details

Patient Name (Required)

Date of Birth

Urgent? (Required)

Yes

Address Line 1 (Required)

Address Line 2

Town (Required)

Post Code

Telephone

E-Mail

Please upload a file if you wish

Browse

Reason for Referral (Required) Discussion with patient or parent (if any)

Patient Consent

Your patient must consent to the provision of their details to Thistle Dental, and must understand what their details are being used for. Your patient can review the referral patient privacy policy at any time, and can request their details are removed.

I confirm that the patient (or patient’s parent or legal guardian) consents to the provision of their personal data (Required)

Yes