Public Dental Referral Form

Refer a Patient Without Creating an Account

Dental Referral Kent makes it easy for dental professionals to refer patients for specialist dental treatment across Kent. Our public dental referral form allows you to submit a patient referral online without registering for an account or signing in.

Whether you are referring a patient for endodontics, periodontology, orthodontics, dental implants or another dental treatment, you can complete the online form with the relevant referral details and supporting clinical information.

Simply provide your dentist and practice details, select the required treatment and receiving clinic, and enter the patient’s information to submit your referral.

No account or login is required to use this form.

Submit Your Dental Referral Online

Complete the secure online referral form below to refer your patient to Dental Referral Kent.

Please ensure that the information provided is accurate and that you have the appropriate authority and consent to share the patient’s personal and clinical information for the purpose of this referral.

    Treatment required *

    Referring Dentist Details

    Please provide your contact and practice details.

    Dentist Name *

    Practice Name *

    Practice Email *

    Practice Telephone *

    Practice Postcode *

    Practice Address *

    Which clinic are you referring to?*

    Preferred clinician View clinician bios

    Patient Details

    Patient First Name *

    Patient Last Name *

    Date of Birth *

    Patient Email *

    Patient Telephone *

    Patient Postcode *

    Patient Address *

    Type of referral *

    Reason for referral *

    Medical history *

    Upload Radiograph(s)/additional x-rays/documents/Photo(s)/Other information - Maximum upload size is 5MB per file

    Privacy and Patient Information

    Please confirm that you are authorised to submit this referral and that the patient has been informed, where appropriate, that their personal and health information will be shared with the receiving dental practice for the purposes of assessing, arranging and providing dental care.

    Please read our Privacy Notice before submitting this referral.

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