Detal Phobia Certified - Grimsargh Smile Clinic Preston
Practice: 01772 651130 
Emergency: 07794 516586 (24 hour emergency line) 
 
Thank you for choosing to refer to us. Please fill out the details below and we will strive to deal with your referral quickly. Alternatively, if you would like to discuss a potential referral, please don't hesitate to contact us by telephone or email, we are always happy to help. Please attach or post any relevant radiographs to us. 

REFERRING GDP 

PATIENT DETAILS 

REFERRAL TYPE (tick as applicable) 

Free Consultation
Assessment
Surgical Only (GDP to restore)
Surgical & Restorative
Root Filling
Re Root Filling
Free Consultation
Crowns/Bridges
Dentures
Tooth Wear
Tooth Whitening
Invisalign
Extraction
Surgical Extraction
Hygienist
Periodontal Disease
Gum recession
Crown Lengthening
Sedation
Dental Sleep Medicine
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