Appointment  |  Patient Referral  |  Find us

 

15 Burlington Crescent, Goole, North Humberside DN14 5EF

 01405 762917

Patient Referral Form


 

Dear colleague, patient referrals can be made to our clinical team by completing the online referral form or contacting the practice directly. If you have any relevant documents / xrays etc, you can email them to us separately at burlingtondental@live.com or post them to us.

 

 

We will inform you of the recommended treatment after the first consultation with your patient, and will keep you fully informed of treatment progress at all times.

 

 

 

Referring Dentist / Practice Name

Referring Dentist Telephone

Referring Dentist Email

Referring Dentist Address

Patient Name

Patient address and Telephone

Medical History of Patient

Treatment Required