Dentist referrals

Name: Guilford Orthodontics
Telephone: 01483 567 772

If you are a dentist who is looking to refer your patient(s) for private orthodontic treatment in Surrey, please fill out the form below. We look forward to working closely with you to protect the health of your patients’ smiles.

New patient referral form

Please fill out the forms below to refer your patient for treatment with braces or clear aligners. We thank you for your referral.

This online referral form is for dentists to refer PRIVATE patients only.

Dentist's details

Dentist Full Name *

Practice Name *

Dentist E-mail *

Any other information

Patient's details

First Name *

Last Name *

Date of Birth

Parents Name (if patient is under 18 years)

E-mail *

Phone *

Patient's Address

Postcode

Please provide an IOTN score (where possible)

Has this patient been registered with another orthodontist before?

If so, who?

Is this patient currently wearing braces, or has done in the past?

For further information about how we use your data, please see our privacy policy.

Contact Us

Eastdale Clinic, 8 Waterden Road Guildford
Surrey GU1 2AP

01483 567 772

admin@guildfordortho.co.uk

Opening hours

Monday - Friday: 8:30am to 5:00pm
Saturday: Open once per month
Sunday: Closed

Some on-site parking

A 2-minute walk from London Road train station
Close to schools

Open in Google Maps