Dental Referral Form

Fill out the form below to submit your referral online, or download a copy to send to us via post. Your referred patient will be given a free consultation with a dental professional so we can discuss their treatment options and associated costs.

If your patient wishes to proceed with treatment, we will then book them in for a clinical examination which costs £90. If you wish to refer to our Specialist Centre for Periodontics and Prosthodontics, the assessment will cost £225. We kindly request that you inform your patient of this before you submit the referral.

Download a Printable Form

Fields marked with * are required.

Specific treatment

If you are a dentist looking to make a referral at one of our practices, Queensway Dental is happy to help.

Specialist Periodontics (Sunderland only)Specialist Prosthodontics (Sunderland only)

Preferred practice

For Specialist Periodontics or Specialist Prosthodontics referrals, please select Sunderland. These are provided only at our Sunderland Specialist Referral Centre.

Sunderland

Patient details

Title *

First Name *

Last Name *

Date of Birth *

Day (e.g. 12)

Month (e.g. 07)

Year (e.g. 1992)

E-mail *Please enter a valid email address.

Phone *Please enter a valid phone number.

Address *

Postcode *

Reason for referral *

Photos & x-rays

Upload any relevant photos or x-rays

Accepted file types: jpg, gif, png, pdf (up to 5 files only; max file size 10MB).

Drag & drop your files here, or

Browse Files

Please give details of any medical conditions and medication.

Relevant medical / dental history *

Referring dentist details

Name *

Phone *Please enter a valid phone number.

E-mail *Please enter a valid email address.

Postcode *

Address *

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

Find Us

Our dentists care for patients across the North East, at eight convenient locations from Newcastle to Middlesbrough. We are a private practice with an NHS oral surgery.

Queensway Dental - Billingham

Crown Buildings, Queensway, Billingham, Teesside TS23 2NU
01642 554 667
reception@queensway.co.uk
Monday – Thursday
8:00am – 7:30pm
Friday
8:00am – 4:30pm

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