Make a Referral.

To refer a patient, please complete the form below and/or email any further relevant information to info@oralsurgerywales.co.uk with the patient’s full name and date of birth.

Your Name

First Name

Last Name

Your E-Mail

Your Phone Number

(###)

###

####

Practice Name and Address

What services are you interested in?

Extraction of 1-2 Teeth

Extraction of 3 or more Teeth

IV Sedation

Treatment details

Patient Name

Patient DOB (DD/MM/YYY)

Patient E-Mail

Patient Phone Number

(###)

###

####

Patient Address

Make a Referral.

Oral Surgery Wales

Location

Contact