Working in partnership with our referring dentists

Making a referral

Our highly experienced clinicians here at Bicester Dental & Implant Clinic accept referrals in the following:

• Private orthodontics
• NHS orthodontics

If you are referring a patient for private orthodontic treatment, please fill in the form below.

Please click the button below if you are referring an NHS orthodontic patient. This will take you Rego where you can login and complete your referral.

NHS referral

Make a referral

This form is for private referrals only. To refer patients for NHS orthodontic treatment, click the link to Rego above.

Patient details (step 1)

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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:

Next stage

Referring Dentist Details (step 2)

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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:

Next stage

Referral Details (step 3)

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

Please select... Dr Hassan Adi

Treatment required *

Please select... Aligners Ceramic braces Children’s braces Invisalign clear aligners Metal braces Teeth straightening

Observations & Dental History

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.

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Confirmation

 I confirm I have the patient's consent to share this information

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Finish

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