For Dental Professionals

Refer a Patient

Refer a patient to Pennypot Dental (Ashford) for specialist care. Please complete all sections below. Your GDC number acts as your electronic signature for this referral.

Referring Dentist

Full name

Practice name

GDC number

Acts as your legally binding electronic signature.

Contact number

Patient Details

Full name

Date of birth

Phone

Address

Referral Details

Treatment required

Urgency

Routine Soon Urgent

Reason for referral / clinical notes

Supporting documents

Click to upload or drag files here X-rays, photos, or records (JPG, PNG, PDF, WebP)

I confirm I have the patient's consent to make this referral and that the information provided is accurate. I understand my GDC number acts as my electronic signature.

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