Refer your patient to Improve Your Smile

Requested treatment

Dental implantsSame-day implantsCT-scanAesthetic dentistryAdult orthodonticsEndodontic treatmentOther (state below)
Please provide further information *

Is the appointment urgent? *

Attach patient files
Medical history sheetX-RaysCastsPhotos
Send up to four files here (must be JPG files of less than 5mb each):

If you have more files to send, please email them to care@improveyoursmile.co.uk

Patient details

Name *

Sex *

Date of birth

Day *

Month *

Year *

Email address *

Telephone number *

Mobile number *

Patient's address *

Medical history notes *

Referring dentist's details

Dentist's name *

Email address *

Telephone number *

Mobile number *

Fax

Dental practice address *

GDC Reg. No. *

* = mandatory field

Thank you for referring your patient to us. We will keep you informed as to our progress and any findings likely to affect their treatment now or in future. We undertake to refer your patient back to you at the end of their treatment with us.
Dr Amjad Malik BDS DGDP RCS (UK), Lead Clinician, Improve Your Smile

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Website last updated: 17th August 2021