Referrals - Eagle House Dental


Please complete the form below to refer a patient to our practice


  • You will be notified once your referral is received.
  • We will contact the patient directly within 2 weeks of receipt of the referral.
  • Our team do not carry out treatment on the first visit and your patient will be invited to attend a consultation appointment.
  • Our Consultation is an investment of £100 which includes photographs, intra-oral radiographs and a tailor made treatment plan report.
  • We take an initial deposit for all of our referral patients of £35 upon booking which is deducted from our consultation fee.
  • We require 48 hours notice if they wish to cancel their appointment otherwise they will lose their deposit.
  • If they fail to attend their appointment, they will lose their deposit and be discharged immediately.
  • If they do not respond or schedule their consultation appointment within 2 months of receipt of the referral, they will be discharged back into your care and a new referral will need to be organised should they wish to move forward at a later date.

Referral Form

Patient Details

Referrer Details

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