Online referral forms – Toothwise

Hurworth Dental Practice

5 Church Row, Hurworth, Darlington, DL2 2AQ

01325 721 999

Online Referral Forms

Toothwise Hurworth Dental Practice welcomes referrals for the following:

Endodontics
Cosmetic/restorative dentistry
Implants
CBCT scans
Invisalign

These can be submitted online or completed and emailed to the practice. Costs associated with referral appointments can be found on our “Fees” page. Please note all referrals will be seen at our Hurworth practice. For more information please do not hesitate to contact the practice.

Referring Dentist Name

Referring Dentist GDC Number

Referring Practice Address

Address Line 1

Address Line 2

City

County

Post Code

Country

Dentist/Practice Email Address (for updates and discharge letters)

Referral Department

Referring Dentist Phone Number

Referral Information

Patient Title

First Name

Last Name

Patient Contact Number

Date of Birth

Patient Email

Patient Address

Address Line 1

Address Line 2

City

County

Post Code

Country

Patient Medical History

Attach X-Rays or Clinical Photos

Choose File

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