New Patient Registration

Select the referral

Implant Sedation CBCT Endodontics

Clinical Justification for X-rays:

Impacted teeth Orthodontics Endodontics

Details of referral and specific teeth(s) required for scan or treatment

Referring Dentist's Name

Referrers Email address

Referrers Phone Number

Upload X Rays / Reports / Images

Our policy is always to ensure patients are returned back to their referring dentists for continuation of treatment and their routine care. If you wish Loughborough Road Dental Practice to provide ongoing dental care to your patient, please confirm below.

No, I wish the patient to be returned to my care once treatment is completed Yes, I would like Loughborough Road Dental Practice to provide the ongoing care

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