Refer Online - Holly House Dental Practice

Online Referral Form

We welcome referrals into the practice from our colleagues. You can be assured of a highly professional solution to your patients Specialist dental requirements. We will make their visit to us as stress free and efficient as you would want it to be. When their specialist treatment is complete they will be returned to your continuing care.

Please call us on: 0161 494 8621

Referring Dentist Title*
Referring Dentist Name*
- Referring Practice Name*
- Patient Name*
- Practice Address*
Patient DOB*
Date Format: DD slash MM slash YYYY
Patient Email*
Patient Tel*
Therapies Requested*
- Periodontal
- Implants‎
- Ortho‎dontics
- Endodontics
RMH*
Reason for Referral*
Previous Treatment*
Oral Hygiene*
- Poor
- Fair
- Good
Upload Radiographs
Accepted file types: jpg, gif, png, pdf, jpeg, docx.
Upload Radiographs
Accepted file types: jpg, gif, png, pdf, jpeg, docx.
Upload Radiographs
Accepted file types: jpg, gif, png, pdf, jpeg, docx.
I confirm I have the patient's permission to share their information:*
- Yes

Referral Form

Online Referral Form

Please call us on: 0161 494 8621

Where we are

Getting in touch

Get directions

Surgery hours

What Our Patients Say

A.Babcock. Woodley

C.Higgins. Stockport

J.Parker. Stockport

G.Pickin. Woodley

C.Cross. Cheshire

Contact

Opening Hours

Referral Form

Online Referral Form

Please call us on: 0161 494 8621

Where we are

Getting in touch

Get directions

Surgery hours

What Our Patients Say

A.Babcock. Woodley

C.Higgins. Stockport

J.Parker. Stockport

G.Pickin. Woodley

C.Cross. Cheshire

Book Online Appoinment