Facial Aesthetics Referral

01903 650222

Thank you for choosing to refer your patient to our Facial Aesthetics team. Our services are designed to enhance natural beauty while maintaining balance and harmony. Using safe, clinically proven treatments, we help soften lines, restore volume, and create subtle, refined results tailored to you.

All treatments are carried out by qualified clinicians in a safe, professional environment with your comfort and wellbeing at the heart of every appointment.

Image of Lady being infected with dermal filler on the face

Facial Aesthetics Referral Form

Please complete the form below to refer patients.

*Indicates required field

Patient details for Facial Aesthetics referral

Address

Postcode

Date of birth

Contact number

Email

Treatment required Treatment required Frown lines Forehead lines Crow's feet Lips Chin

Reason for referral

Relevant Medical history

Image upload (if relevant). File name to include referring dentist name, patients initials and patient DOB File InputNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, png. Max. file size: 1 MB

Referring dentists details I have explained the need for referral and obtained my patient's consent for the treatment to be carried out.

GDC Reg No.

Practice name

Practice address

Postcode

Practice Email

Practice contact number

Additional comments

Practitioner Authorisation and Responsibility Statement

I confirm that:

The patient has been examined by me and is fit for treatment.
All relevant clinical information provided is accurate to the best of my knowledge.

By submitting this referral, the referring dentist acknowledges that:

Our practice will assess the patient and recommend treatment based on suitability.

Final treatment planning decisions rest with the Facial Aesthetics specialist in accordance with professional standards.

Our dental practice accepts no liability for pre-existing conditions or incomplete information provided at the point of referral.