Dentist Referrals

We accept referrals from dental professionals for dental implants, surgical extractions, oral surgery procedures, OPG imaging and CBCT scans.

Coach House Dental Care

Dental Referral Form

Complete the form and submit the referral securely to our clinic.

Patient Details

Patient Name *

Email Address *

Phone Number *

Address *

Referring Dentist Details

Dentist Name *

GDC Number * Enter the referring dentist’s numeric GDC registration number.

Email Address *

Phone Number *

Practice / Clinic Name *

Practice Address *

Referral Request

Treatment or imaging requested *

Supporting Files Optional

Attach up to two X-rays, clinical photographs or PDF documents. Maximum 5 MB per file.

Attachment 1 JPG, PNG, WebP or PDF.

Attachment 2 JPG, PNG, WebP or PDF.