✕

About
Dental Implants
Cosmetic
Sedation
Patient’s Area
Referrals

About
Vision & Values
Meet the team
Dental Implants
CBCT Scan
Dental Implants
All-On-X Implants
IV Sedation
Fees & Finance
Cosmetic
Exam & Consultation
Dental Imaging
Hygiene & Gum Treatment
Clear Aligner Orthodontics
Invisalign
Composite Bonding
General Dentistry
Facial Aesthetics
Fees & Finance
Sedation
Nervous & Phobic Patients
What to Expect?
Book a Consultation
Dentist Referral
Fees & Finance
Patient’s Area
New Patient Registration
Online Booking
Dental Blogs
Complaint's Procedure
Privacy Policy
Referrals

phone

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✕

About
Dental Implants
Cosmetic
Sedation
Patient’s Area
Referrals

About
Vision & Values
Meet the team
Dental Implants
CBCT Scan
Dental Implants
All-On-X Implants
IV Sedation
Fees & Finance
Cosmetic
Exam & Consultation
Dental Imaging
Hygiene & Gum Treatment
Clear Aligner Orthodontics
Invisalign
Composite Bonding
General Dentistry
Facial Aesthetics
Fees & Finance
Sedation
Nervous & Phobic Patients
What to Expect?
Book a Consultation
Dentist Referral
Fees & Finance
Patient’s Area
New Patient Registration
Online Booking
Dental Blogs
Complaint's Procedure
Privacy Policy
Referrals

phone

whatsapp transparent

Referrals

To be completed by dentist only.
For patients please contact us or complete a new patient registration form

Referral Guidelines

To refer your patients to our clinic please complete the form
Include all clinical relevant information for e.g. treatment plan
For OPG & CBCT justification and site details is required.

All CBCT referring dentist will require CBCT level 1 training.

Please enable JavaScript in your browser to complete this form.

Referral Reason - Step 1 of 5

Select Referral Reason:

OPG Radiograph
CBCT Scan
IV Sedation
Dental Implantology
Wisdom Tooth Removal
Difficult Tooth Extraction
Full Mouth Rehabilitation

IV Sedation Referral Guidelines

Please ensure your patient is asware of the following:

1. An initial assessment appointment will be arrange to find out if they are suitable for IV Sedation.
2. A deposit of £50 will be taken from all patients prior to booking the initial consultation.
3. Once the treatment plan is formulated, the full payment is taken prior to booking the IV Sedation & treatment appointment.
4. The escort is not required to attend at the first initial assessment, but are welcome to attend.

Wisdom Tooth Removal Referral Guidelines

Please ensure your patient is asware of the following:

1. An initial assessment appointment will be arrange to find out if they are suitable for Surgical Wisdom Tooth Extraction
2. A deposit of £50 will be taken from all patient prior to booking the initial consultation.
3. Once the treatment plan is formulated, the full payment is taken prior to booking the wisdom tooth extraction appointment.
4. If a periapical radiograph has been attempted, please attach to this referral (at the final step).
5. If an OPG is required, please inform the patient that there be additional cost.

Dentist's Name *

GDC Number *

Dentist's Phone Number *

Dentist Email *

Email

Confirm Email

Practice Name *

Practice Address *

Practice Postcode *

Confirmation of IRMER Referrer Training *

Yes
No

I have undertaken training required to satisfy the minimum criteria as an IRMER Referrer / Conebeam CT which is covered on pages 49-53 of the Guidance of Safe Use of Dental Cone Beam CT (Computed Tomography) Equipment prepared by the HPA Working Party on Dental Cone Beam CT Equipment. (Click to read guidance notes)

You must have undertaken training required to satisfy the minimum criteria as an IRMER Referrer / Conebeam CT which is covered on pages 49-53 of the Guidance of Safe Use of Dental Cone Beam CT (Computed Tomography) Equipment prepared by the HPA Working Party on Dental Cone Beam CT Equipment to request a CBCT image. YOU WILL NOT BE ABLE TO CONTINUE WITH THIS REFERRAL

Patient's Name *

Patient's Date of Birth *

Patient's Phone Number *

Patient Email

Patient's Address *

Patient's Postcode *

Patient Payment Options *

Private Fees Information

Please ensure your patient is asware of the following:

1. An initial assessment cost is £50.
2. All treatment cost is paid prior to booking the treatment appointment.
3. Full private treatment item cost is available: Click Here

Private referral confirmation *

I can confirm that the patient is being referred to WestCity Dental Implant & Cosmetic Clinic as a private patient and the above information has been or will be passed on to the patient.

Select Arch

Maxilla
Mandible
Full Arch

Anatomy to Include

Sinus
Zygoma
TMJ

Delivery Option

Patient (USB Drive & Email)
Referring Dentist (Email)
Both

In accordance with IR(ME)R 2000 a clinical justification must be provided for each dental CBCT scan and the scan must be
clinically evaluated by someone trained in the analysis of dental CBCT scans.

Reason for referral & justification for scan *

Special Instructions to IRMER operator involved in scan acquisition *

Proposed Treatment Plan *

File Upload - Attach any treatment plan, specialist letters and radiographs

Click or drag files to this area to upload. You can upload up to 10 files.

Consent Confirmation *

I consent to my personal data being collected and stored as per the Privacy Policy.

Custom Captcha *

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Why you should choose us?

Over 20 years experience in dentistry & patient care

Over 14 years experience in dental implants, IV sedation & facial aesthetics

over 20 years experience in patient care and management of nervous patients.

Don't wait and make an appointment today

Book an appointment

381 Harrow Road
Maida Hill
London W9 3NA

Opening hours:

Mon - Thurs:	9 AM - 5 PM
Friday:	9 AM - 1 PM
Saturday:	By appts only
Sunday:	Closed

Contact Form

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1Enquiry

2Your Personal Details

3More info

4Submit

Are you currently registered with WestCity Dental Implant & Cosmetic Clinic *

Yes
No
I am not sure

Select your enquiry *

Select your enquiry: *

Confirmation *

I am aware that this is a PRIVATE dental clinic and I am happy with the private fees as set by WestCity Dental Implant & Cosmetic Clinic.

Name *

First

Last

DOB *

Email *

Your Phone Number *

Choose a dentist

PLEASE COMPLETE THE QUESTION BELOW ABOUT YOUR DENTAL ISSUE:

Describe the pain? Sharp, dull, throbbing?

How long have you been experiencing this pain?

Select Pain level (0 = Very Mild, 10 = Severe

Pain Level: 1

Is the pain constant or does it come and go?

Triggers

Swelling?

Recent Dental Work

Other Symptoms

Medications taken?

Please take a photo of your swollen face or the problem area:

Click or drag a file to this area to upload.

Take a photograph of your teeth for a free online assessment:

Click or drag a file to this area to upload.

Any other important information: *

Checkboxes *

I consent to my personal data being collected and stored as per the Privacy Policy.

Custom Captcha *

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Email

Maps

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Please enable JavaScript in your browser to complete this form.

1Enquiry

2Your Personal Details

3More info

4Submit

Are you currently registered with WestCity Dental Implant & Cosmetic Clinic *

Yes
No
I am not sure

Select your enquiry *

Select your enquiry: *

Confirmation *

I am aware that this is a PRIVATE dental clinic and I am happy with the private fees as set by WestCity Dental Implant & Cosmetic Clinic.

Name *

First

Last

DOB *

Email *

Your Phone Number *

Choose a dentist

PLEASE COMPLETE THE QUESTION BELOW ABOUT YOUR DENTAL ISSUE:

Describe the pain? Sharp, dull, throbbing?

How long have you been experiencing this pain?

Select Pain level (0 = Very Mild, 10 = Severe

Pain Level: 1

Is the pain constant or does it come and go?

Triggers

Swelling?

Recent Dental Work

Other Symptoms

Medications taken?

Please take a photo of your swollen face or the problem area:

Click or drag a file to this area to upload.

Take a photograph of your teeth for a free online assessment:

Click or drag a file to this area to upload.

Any other important information: *

Checkboxes *

I consent to my personal data being collected and stored as per the Privacy Policy.

Custom Captcha *

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Message