Submit A Referral

    Quick Enquiry

    We constantly strive for excellence in our clinical and customer care standards

    If you would like to refer a patient to us, you can either download our form to fill in and send to us or you can submit your referral online.

    Our experienced team of friendly highly trained and caring professionals will ensure that you receive maximum attention with our personal touch.

    The Centre is ideally located in the small village of Hampton Wick a short walk from Kingston Town Centre and close to Teddington High Street.

    Click here to download a Referral Form

    Online Referral Form

    Fields marked with an * are required.

      Patient Details:

      Title

      Name *

      Date of birth

      Home address *

      Mobile number*

      Home telephone*

      Work telephone *

      Email *

      Dentist Details

      Practice *

      Address*

      Dentist *

      Business email *

      My patient is being referred for:

      Periodontics

      Oral Surgery

      Hygiene

      Endodontics

      Invisalign®

      Zoom Whitening

      Implants

      Cosmetic Surgery

      Facial Aesthetics

      The reasons for my referral are

      Additional information about my patient

      Medical history details

      My patient requires oral sedation/intravenous sedation

      My patient may need interest free credit

      My patient is covered by private insurance