Referrals

Refer a patient

Complete the form below to send your referral securely to the Eastdale team.

Start a referral PDF referral form

Practice contact:hello@eastdaledental.co.uk

For clinicians

Secure referral intake

If you have any questions about the referral process, please contact the practice team directly.

Fields marked are required. All other fields are optional.

Referrer

Clinician namePractice name

GDC number (optional)

Practice email (optional)Practice phone (optional)

Provide either practice email or phone (or both).

Sign me up to the referrer newsletter — occasional CPD events, study club evenings and clinical updates, sent to the practice email above. You can unsubscribe at any time.

Practice address line 1 (optional)Practice address line 2 (optional)City (optional)Postcode (optional)

Patient

First nameLast name

Date of birthPatient phone

Patient email (optional)Patient postcode (optional)

Preferred contact method (optional)PhoneEmailLeave blank if the patient has no preference.

Clinical context

Reason for referral0 / 2000

I confirm the patient has consented to this referral and the sharing of any attached records, and that the information supplied is accurate.

Attachments (optional)

Drop files here or .

Up to 20 files, 250.0 MB total.

Files stay on your device until you press Submit referral — they are uploaded securely as part of the submission.

No files added. Attachments are optional — include DICOMs, PDFs, or images if you have them, or submit the referral without any.

Selected: 0 / 20 files · 0 B / 250.0 MB

Complete the verification check before submitting.