Please find below referral forms for Orthodontics, Periodontology, Oral Surgery/Implants and 3 D X-rays.  All of our forms can be downloaded and emailed to our NHS net account (holywell.house@nhs.net), please email us from your NHS net account.

Orthodontic Referral form

If you are a dentist and would like to refer a patient for NHS/Private Orthodontics, please complete and return the Orthodontic Referral form.

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Periodontal Referral form

If you are a dentist and would like to refer a patient for private Periodontal Treatment, please complete and return the Periodontal Referral form.

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Oral Surgery and Implant Referral form

If you are a dentist and would like to refer a patient for private Oral Surgery/Implants, please complete and return the Oral Surgery and Implant Referral form.

If you would like to send a patient for NHS Minor Oral Surgery, please complete the NHS Warwickshire/NHS Leicestershire County and Rutland Minor Oral Surgery Referral forms.  For Leicestershire these forms need to be sent direct to the PCT.  For Warwickshire please post the forms direct to the practice.

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3D X-ray Referral form

If you are a dentist and are interested in using our 3D X-ray machine then please complete and return the form.

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3D XRAY

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