Victoria Dental Centre - Dentists Patient Referral

This page is for dentists referring patients to Victoria Dental Centre only. To help us deal with your request promptly all areas marked with an asterisk must be completed. Unless otherwise requested, all patients who have been referred to our specialists will be returned back to you once treatment has been completed. We will keep you informed about the progress of the treatment.

We will be happy to hear from you at any time if you have questions or queries or if you would like to discuss any aspect of your patients treatment with us.

Patient Details

Name: * Please add the patients NameInvalid format.
Date of Birth: * Please add the patients Date of BirthInvalid format.
Address: * Please add the patients address
Telephone: * Please add the patients telephone numberInvalid format.
Email:
Reason for referral: * Please add the reason for referral
Attachment(s):

(Alternatively you can post the radiographs to us, we will scan them in and send them back straight away)

Consultation referral for: * Please indicate which treatment your referral is for by selecting one of the below:
Implants & Prosthetics - Dr A J Chaudhuri (1hr consultation + records £110.00 - £175.00)
Periodontics - Dr Dominki Chazapoulou (40 min Consultation + start treatment £135.00 - £150.00)
Endodontics - Dr Vanderley Da Silva (40 min consultation+ x-rays (£60.00 - £95.00)
Orthodontics - Dr. Richard Goulart (1hrs consultation, imps + photos (£90 .00 - £150.00)
Invisalign & 6month Smile - Dr Andrew McCarthy ( £60.00 consultations + records)
Cosmetic Dentistry - Dr Ronak Patel (40mins Consultation + imps £60.00)

Referring Dentist

Name: * Please add your nameInvalid format.
Practice:
Your Email: * Please add a valid EmailEmail appears an invalid format
Phone: * Please add your telephoneInvalid format.
Any Additional Comments: