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Dentist Referral Form

Whether you are another specialist, dentist or allied healthcare professional we would be most grateful for your referral. We can assure you that your patients will:

  • Be treated with respect, dignity and care that you would expect.
  • Receive a comprehensive orthodontic report outlining treatment.
  • Be encouraged to maintain their regular dental care and hygiene with yourselves.

We will ensure:

  • You will receive a comprehensive clinical report keeping you informed at all times.
  • You are kept updated of any treatment proposals and seek your approval where required.
  • No patient referred to our practice will be referred to another practitioner without both your own and your patient’s consent.

We are happy to accept online referrals using the referral form below, or alternatively you may refer in writing to us at: Origin Orthodontics, 19 Wimpole Street, Marylebone, London, W1G 8GE or by email info@origin-orthodontics.co.uk


Please fill in all fields marked with *

Dentist name & address

Patient details

Patient contact details

Clinical details (Please tick as appropriate)

Please indicate if your patient has any particular treatment preferences

Image upload (Select one or multiple files)

Browse and upload individual images of your patient's teeth (.jpg, .jpeg, .tif) up to 6 files (6MB per file)

All photographs submitted to us will be kept strictly confidential and not shared with any third party.

An orthodontist will review the information and be in touch shortly.

For further information about how we use your data, please see our privacy policy.

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