REFERRAL FORM

Chestnut Smile Centre Ltd are offering a referral service for some oral surgery procedures.  We are offering treatment provided by a dentist with a special interest in oral surgery. 

For their first appointment, all patients will require a new patient consultation prior to undergoing their treatment.

Patients can be referred by dentists via the referral form below.  Referrals will be triaged and we will notify you if your referral is accepted, declined, or if we require further information.  We can offer OPGs if required.For any patients wishing to self-refer, please contact the practice using the contact details on the contact us section.

Chart tooth for extraction - Upper Right

Chart tooth for extraction - Lower Right

Relevant medical history​. Please tick as appropriate 

NB if referring a lower wisdom tooth, please provide an OPG.  If you do not have access to an OPG machine, please state below and we can arrange this at the practice for a fee.

Chart tooth for extraction - Upper Left

Chart tooth for extraction - Lower Right

Prices

If accepted for treatment, patients will be required to pay a deposit towards treatment to secure their appointments.  If patients fail to attend, this deposit will be non-refundable.

Consultation fee £75

Intravenous sedation £325

Lower wisdom tooth extraction from £350

Surgical/complex extraction from £280

Simple anterior extraction from £180

Simple premolar/molar extraction from £225

Coronectomy from £350