Private Patient Referrals

If you’re a general practitioner and would like to refer your patient or you would like to self-refer yourself to our team for private dental specialist treatment for orthodontics, then please submit your details using the form below.

Home » Dentist Referrals

Referring your patient to us

We accept referrals from more than 200 dental practices from across the Midlands, and the number is growing.

We are taking special care to make sure the high-quality patient experience remains the same. If you would like to refer a patient to us please use the form below.

Why refer your patient to One Devonshire Place for orthodontics?

More than 10,000 cases completed
Specialist orthodontists have extra training and experience
More choices with our full range of systems
Private treatment = no waiting lists
Pay as you go
Free onsite parking
Open six days a week
Trusted by 200 referral dental practices across the Midlands
Treatments tailored to your needs
We monitor dental development
After-school appointments
Treatments designed to reduce the impact on sports and playing musical instruments.

Dentist’s Referral Form

“*” indicates required fields.

For information about how we will use your details, please see our Privacy Notice.

Patient Details

Patient First Name *

Patient Last Name *

Patient Address - Line 1 *

Patient Address - Line 2

City/Town *

Postcode *

Patient Date of Birth *

Patient Email *

Patient Mobile *

Referring Dentist's Details

Dentist First Name *

Dentist Last Name *

Dentist Practice *

Dentist's Phone Number *

Dental Practice Address - Line 1 *

Dental Practice Address - Line 2

Dental Practice City/Town *

Dental Practice Postcode *

Referring Dentist Email Address *

Referral Details

Main reason for referral and/or patient’s concern *

Oral Hygiene Status

Teeth of Poor Prognosis?

History of Dental Trauma? (State teeth)

Relevant Medical History

Do You Have Any Files You Wish To Attach In Support Of This Referral? *

Would you like to carry out any restorative procedures ie whitening, composite bonding, at your practice following orthodontic treatment? *

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