Refer a Patient

Form for Dentists to earn £50 referral fee

Dentist's Name *

First

Last

Dentist's GDC Number *

Dental Practice Name and Address *

Dental Practice Postcode *

Dentist's Contact Number *

Dentist's Email Address *

Patient's Name *

First

Last

Patient's DOB DD/MM/YYYY *

Patient's Gender *

Male
Female
Prefer not to say

Patient's Contact Number *

Patient's Email *

Patient's Address *

Patient's Postcode *

Service Required *

Treatment Required In Words *

Does your patient require intravenous sedation? *

Additional Notes (Optional)

I would like to benefit from a £50 referral benefit once the patient receives treatment. Treatment fees are identical in either circumstance

Yes, I'd like £50
No, I'd like to refer without a fee

Bank Account Number for Referral Payment

Sort Code for Referral Payment

Bank Account Name for Referral Payment

I confirm that I have received my patient's approval to share their details with Expedentist. My patient understands that a representative from Expedentist will make contact using the details provided to arrange an appointment for treatment to take place *

I confirm