DenGro Referral Form

Welcome to the syncdental Referrals portal!

In order to avoid rejection, please complete the following information:
Select your practice:*
(i) This is the practice you are referring from.
Your GDC number:*
Identification:*
(HOOK) Clinician Address 1*
(HOOK) Clinician Address City*
(HOOK) Clinician Address Post Code*
(HOOK) Clinician Email*
(HOOK) Clinician Phone*
(HOOK) Clinician First Name*
(HOOK) Clinician Surname*
Addlestone - Address Line 1
Addlestone - Town/City*
Addlestone - Post Code
Addlestone - Email
example@example.com
Chertsey - Address Line 1
Chertsey - Town/City*
Chertsey - Post Code
Chertsey - Email
example@example.com
Guildford - Address Line 1
Guildford - Town/City*
Guildford - Post Code
Guildford - Email
example@example.com
Parkside - Address Line 1
Parkside - Town/City*
Parkside - Post Code
Parkside - Email
example@example.com
Pyrford - Address Line 1
Pyrford - Town/City*
Pyrford - Post Code
Pyrford - Email
example@example.com
Roseneath - Address Line 1
Roseneath - Town/City*
Roseneath - Post Code
Roseneath - Email
example@example.com
Wimbledon - Address Line 1
Wimbledon - Town/City*
Wimbledon - Post Code
Wimbledon - Email
example@example.com
Windsor - Address Line 1
Windsor - Town/City*
Windsor - Post Code
Windsor - Email
example@example.com
Dentally Number

Patient Details

In order to avoid rejection, please complete the following information:
Patient Name*

First NameLast Name
Patient Email Address*
example@example.com
Patient Contact Number*
(i) Please enter a UK mobile number
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Date of Birth*

DayMonthYear

Referral Details

In order to avoid rejection, please complete the following information:
(HOOK) Unique Identifier*
ADDLESTONE IDENTIFIER
CHERTSEY IDENTIFIER
GUILDFORD IDENTIFIER
PARKSIDE IDENTIFIER
PYRFORD IDENTIFIER
ROSENEATH IDENTIFIER
WIMBLEDON IDENTIFIER
WINDSOR IDENTIFIER
Which practice would you prefer for your patient to be seen at?*
If the required service is not available at your chosen practice, a TCO will contact you and provide alternative options.
What treatment do you wish to refer your patient for?*
CBCT and OPG Scans can only be taken at Addlestone (OPG only), Guildford, Parkside, Pyrford, and Windsor.
Which clinician do you want to refer to?
Composite Bonding or Veneers
Which clinician do you want to refer to?
Sync Smiles (Combined Orthodontics, Whitening, Bonding)
Which clinician do you want to refer to?
Dental Implants
Which clinician do you want to refer to?
Orthodontics
Which clinician do you want to refer to?
Periodontics
Which clinician do you want to refer to?
Endodontics
Which clinician do you want to refer to?
Oral Surgery
Which clinician do you want to refer to?
Dentures
Which clinician do you want to refer to?
Facial Aesthetics
Which clinician do you want to refer to?
Sedation
Imaging Referral (Config)
Hidden

Referral Details

In order to avoid rejection, please complete the following information:
Referral Details
(i) Please include any clinically necessary information, as well as, whether your patient is nervous or has requested sedation.
Attachments

(i) Radiographs, pictures, documents.
Cancelof
Diagnostic Imaging Details
(i) Please include any clinically necessary information, such as the region of interest.
Do you want a copy of this scan sent to you directly?
Does your patient want a copy of their scan provided to them?
Does your patient require a radiology report?
Please specify reporting details:
Please provide the details of the company handling the referral:
Should be Empty: