Make a referral

To refer a patient to Capel Dental Care, simply complete and submit the below referral form.

Please include all relevant clinical information regarding this case, and remember to attached any x-rays if relevant.

After reviewing, we will contact the patient to introduce ourselves and book them in. We will also keep you fully updated on progress throughout.

Patient details (step 1)

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First name *

Last name *

Address 1 *

Address 2 *

Postcode *

Date of birth *

Contact number *

Email *

Please check that the following fields have been filled out correctly:

Referring Dentist Details (step 2)

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First name *

Last name *

Phone number *

Practice name *

Practice address line 1 *

Practice address line 2

Practice city *

Practice county *

Practice postcode *

Email address *

Please check that the following fields have been filled out correctly:

Referral Details (step 3)

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Enter the name of the relevant clinician to refer your patient to (if known)

Treatment required *

Reason for referral/treatment required. Please detail relevant dental history and preferred clinician if applicable

General assessment of dental health

Oral hygiene *

Poor Fair Good Other

Teeth of poor prognosis *

Relevant medical history *

Additional files
- Please note that only the following file types are supported: jpeg, jpg, png, gif, pdf, doc, docx, xls, xlsx, rtf, ppt, odt.

Add more files

Please check that the following fields have been filled out correctly:

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Title:

First Name:

Last Name:

Email Address:

Telephone:

Mobile:

Postcode:

Preferred contact time:

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Message:

Confirmation

I understand that by submitting this form, it will be shared with the practice, following which a member of the team may contact me to discuss, if required. View our privacy policy to learn more about how we use your data.

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