01962 841009St Lawrence House, 2 Barnes Close, Winchester SO23 9QX
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Dental Referrals

At Winchester Orthodontic Practice, we value the trust placed in us by our referring dentists and are committed to providing exceptional specialist care for every patient you send our way. Whether you are referring for a CT scan or specialist orthodontic treatment, our team ensures a smooth, transparent, and collaborative process from start to finish.

Orthodontic Referral Form

CT Scan Referral Form

Dentist Details

Dentist Name (Required)

Patient Details

Name
Parents Name
Patient Address

Patient Records

Do you have an OPG or equivalent available? (Required)

Max. file size: 8 MB. PDF, JPG or PNG.

Privacy Policy (Required)
Marketing Consent

Patient Details

Name (Required)

Referring Dentist Details

Dentist Name (Required)

CT Scan Requirements

All scans will be parallel to the occlusal plane unless otherwise specified. Radio-opaque markers to be worn? Yes/No (Required)
CT Scan Charges (Required)
DISCLAIMER (Required)

Winchester Orthodontic Practice is a trading style of Winchester Smiles Limited who are authorised and regulated by the Financial Conduct Authority (FCA No 987490). Finance is subject to availability, status and income, applicants must be 18 or over. Terms and Conditions apply. Registered office: Chester House, Lloyd Drive, Ellesmere Port, England, CH65 9HQ.

All finance is subject to availability, status and income.