Referral form| Bingley | Villa Dental & Implant Clinic

2 Priestthorpe Lane , Bingley, West Yorkshire BD16 4ED

Book Book an appointment

New: 01274 271700

Existing: 01274 271700

Home
Meet the team
Treatments
Plans & fees
Referrals
Get in touch
Articles

Referrals
Referral form

Patient details (step 1)

click to open click to close

First name *

Last name *

Address 1 *

Address 2 *

Postcode *

Date of birth *

Contact number *

Email *

Please check that the following fields have been filled out correctly:

Referring Dentist Details (step 2)

click to open click to close

First name *

Last name *

Phone number *

Practice name *

Practice address line 1 *

Practice address line 2

Practice city *

Practice county *

Practice postcode *

Email address *

Please check that the following fields have been filled out correctly:

Referral Details (step 3)

click to open click to close

Enter the name of the relevant clinician to refer your patient to (if known)

Treatment required *

Reason for referral/treatment required. Please detail relevant dental history and preferred clinician if applicable

General assessment of dental health

Oral hygiene *

Poor Fair Good Other

Teeth of poor prognosis *

Relevant medical history *

Additional files
- Please note that only the following file types are supported: jpeg, jpg, png, gif, pdf, doc, docx, xls, xlsx, rtf, ppt, odt.

Other records sent via post

Radiographs Study models Diagnostic wax up None Other

Final restoration to be placed by:

The Referring Dentist By Villa Dental & Implant Clinic

Any comments

Confirmation

I confirm I have the requisite authority to share the patient's information in connection with this referral

Please check that the following fields have been filled out correctly:

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Portman Dental Care Awards

Dental Industry Award - Portman Dental Care

Elite Practice Award - Portman Dental Care

Private Dentistry Awards - Portman Dental Care

Villa Dental & Implant Clinic is a trading name of Portman Healthcare Limited registered in England and Wales: 06740579. Registered office: Rosehill, New Barn Lane, Cheltenham, Glos, GL52 3LZ.
Portman Healthcare Limited is an appointed representative of Product Partnerships Limited which is authorised and regulated by the Financial Conduct Authority. Product Partnerships Limited’s FCA registration number is 626349 and its address is Second Floor, Atlas House, 31 King Street, Leeds LS1 2HL. Product Partnerships Limited’s permitted business is to act as a Principal for a network of Appointed Representatives who arrange regulated credit facilities for customers who are purchasing goods from them.

Portman Healthcare Limited (FRN: 700090) acts as a credit broker not a lender. We can only introduce you to Secure Trust Bank T/A V12 Retail Finance Limited (FRN: 679653) who may be able to offer you finance facilities for your purchase. We will only introduce you to this lender. We do not receive any commission for introducing customers to a finance provider. Credit is provided subject to affordability, age, and status. Minimum spend applies. Not all products offered by Secure Trust Bank PLC are regulated by the Financial Conduct Authority.

Copyright © 2025 Portman Healthcare. All rights reserved.

Last updated 14/08/2020 at 13:31

Get in touch
About Portman
Legal
Privacy Policy
Complaints
Careers
Terms and conditions