Apollonia House Referral Form

Patients will only receive the treatment they have been referred for and will be returned to the referring practitioner on completion of treatment.

To make a referral, please complete the online referral form below, and click on the submit button, or if you prefer, print the form and send it with relevant radiographs to the address shown below.

For further information please telephone Natalie on 01457 821800.
Apollonia House Referral Form
Referral for
Other
Treatment Requested:
Patient details:
Name

PrefixFirst NameMiddle NameLast Name
Date of Birth

DayMonthYear
Address

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Telephone Number
Mobile Number
E-mail
Reason for Referral
Relevant Medical History
Referring Dentist Details
Referring Dentist

PrefixFirst NameLast Name
Practice Name
Address

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Telephone Number
E-mail
Date of Referral

DayMonthYear
Please send any relevant radiographs by post or email and they will be returned to you on completion of treatment
Send us this form by email by clicking 'Submit Form', or if you prefer, you can print and send it to:-

Natalie Bennett, Apollonia House, 167 Mossley Road, Grasscroft, Uppermill, Oldham OL4 4HA
Should be Empty: