1. Finally, It would be beneficial to us if you could be take a photo of your smile showing your teeth and the image (Optional)

Thank you. We'll be in touch to book your free consultation.

If you would like to book a free consultation to discuss your condition and the treatment options available please complete and submit this form.

courses &
referrals

Let our team be an extension of your team

G ive your clients the solutions they deserve when you need to refer them for specific dental treatments. Our referral service is available for Dentists throughout Cheltenham, Cirencester and Gloucestershire. From sophisticated computer driven dental technology to an in-house laboratory, Cheltenham Dental Spa has some of the best technology available.

We also have a team of highly skilled professionals dedicated to delivering excellence when you refer your clients to us.

Want to meet the Team?
Give us a call and lets get it scheduled.

By referring clients to us, you ensure they get the very best treatment from yourselves as well as your extended Team.

We are currently accepting referrals for:

  • Orthodontics
  • Bone Grafting
  • Panoramic X-Rays
  • Cone Beam CT scan
  • Same Day Teeth
  • CEREC same day crowns
  • Sedation Clinic
referral form options

1-imgpdf download

For your convenience we offer two options. Choose this option to open or save either form as a PDF file - for printing, completing by hand and letter posting to us at: Cheltenham Dental Spa, 1 Royal Crescent, Cheltenham, GL50 3DB. We’ll be in touch soon after.

pdf-1 pdf-1

Dental implants, Bone grafting
and Orthodontics

pdf-1 pdf-1

x-rays and cbct

2-imgonline form

You may find it more efficient to complete either form online. Just click on the title below to open a form, complete as necessary and submit. We will receive confirmation of your submission and a PDF file of your completed form. We’ll be in touch soon after.

Dental implants, Bone grafting and Orthodontics
patient details
TITLE
FULL NAME
ADDRESS
DOB
TELEPHONE
E-MAIL
Referring Dentist Details
TITLE
FULL NAME
PRACTICE NAME AND ADDRESS
GDC NUMBER
TELEPHONE
E-MAIL
SIGN WITH YOUR INITIALS
implants
  • Service Level 1: Assessment Only
  • Service Level 2: Implant Placement Only
  • Service Level 3: Augmentation
  • Service Level 4: Complete Treatment
What are levels of referral?
Level 1:

Opinion and assessment only.

A single appointment to discuss options and costs and may include an OPT or cone beam CBCT scan.

Level 2:

Implant placement only.

Implants placed after an assessment and planning all restorative aspects are carried out by the referring dentist.

Level 3:

Bone grafts and Sinus augmentation

After the augmentation treatment the implant placement is carried out by the of referrer.

Level 4:

Full treatment.

The patient is referred tous for all phases of treatment including assessment, surgical and restorative phases.

Restorative and Aesthetic
  • Crown and Bridge
  • Veneers
  • Orthodontics
  • Restorative / Aesthetic
  • Aesthetic
Other
  • Root Canal Treatment
  • Extractions
  • Hygienist / Periodontal
Patient complaint / Reason for referral
Relevant medical history
How did you hear about us
date
X-rays and CBCT
patient details
TITLE
FULL NAME
Home Address
dob (dd/mm/yyyy)
TELEPHONE
E-MAIL
Referring Dentist Details
TITLE
FULL NAME
PRACTICE NAME AND ADDRESS
GDC NUMBER
TELEPHONE
E-MAIL
Scan Regions
  • opt
  • Cone Beam CT Scan
  • 8
  • 7
  • 6
  • 5
  • 4
  • 3
  • 2
  • 1
  • 8
  • 7
  • 6
  • 5
  • 4
  • 3
  • 2
  • 1
Scan Size (Indicate Area on Diagram Below)
  • Mandible / Maxilla (8 x 8)
  • Sextant (5.5 x 5)
  • 8
  • 7
  • 6
  • 5
  • 4
  • 3
  • 2
  • 1
  • 8
  • 7
  • 6
  • 5
  • 4
  • 3
  • 2
  • 1
Justification for Scan (Mandatory)
Scan Information
I confirm I will provide my own Radiographic Report. Yes No
Do you have a scan stent to be fitted? Yes No
Fees
All fees to be paid at the time of the appointment by the patient, please indicate that you have explained this to the patient Yes
Scan without report £95
5.5 x 5 Scan with report £200
8 x 8 Scan with report £220
please note

To comply with IMER 2000 regulations all radiographs and scans must be reviewed and reported into the clinical records by the referring practitioner or by anappropriately trained individual. We strongly recommend that all scans and other radiographic examinations should be reported upon to rule out the possibility ofcoincidental pathology. If the referring practitioner prefers that they make their own arrangements for the reporting, please let us know in advance.

How did you hear about us
Date (dd/mm/yyyy)

If you would like to personally discuss the case you wish to refer with one of our Dentists or Specialists, please request a call back stating best time to call together with preferred number, or email your enquiry to enquiries@cheltenhamdentalspa.com.

We guarantee everything you share with us remains in the strictest confidence at all times.