Please note currently we are not accepting new patients. We apologise for any inconvenience caused.

Referral Form

    Patients Details

    Referring Dentist

    Relevant Medical History

    Current Medication

    Sedation Required*

    Please advise patients attending sedation that:
    i) IV sedation requires 4hr fast before treatment.
    ii) They must be accompanied by a responsible adult who can drive/transport them home AND supervise them for at least 6hrs after treatment.

    Proposed Treatment

    Any part of the treatment you propose to complete?

    Radiographs included?

    Radiographs type & number

    File attachments

    Any additional information?

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    Contact us today to book your appointment

    Call us on +44 28 4066 2034 or email info@cliffgardental.com