Refer a patient (dental professionals only)

If you would like to refer a patient to Dental Health Spa please fill out the following form and we will contact the patient by telephone during our working hours:

Monday:	12am - 8pm
Tuesday:	9am - 6pm
Wednesday:	9.30am - 8pm*
Thursday:	9am - 8pm
Friday:	9am - 4pm
Saturday:	9am - 3pm
Sunday:	Closed

Pre-booked appointments also available between 8am and 9am. Please contact us for more information.

*To ensure that you receive the best quality service, we are closed between 8.30am and 9.30am on Wednesdays for staff training.
**Open on alternate Saturdays only. Please contact us for more information.

If they require an appointment within the next 24 hours please contact us on 01273 710831.

Alternatively you can download a copy of our referral form by clicking here.

When you have completed the form please call us to book an appointment on 01273 710831, then fax the form to 01273 710820, or post to Dental Health Spa, 14 - 15 Queens Road, Brighton, BN1 3WA.

Referring dentist's details     Practice name:     Practice address:     Postcode:     Telephone no.:     Email:     GDC no.:             Patient details     Title:     Full name:     Address:     Postcode:     Daytime tel:     Email:         Date of birth:   Treatment plan - criteria for referral     Smoker?: yes no       If yes, average number of cigarettes smoked per day:             BPE: Periodontal Examination     Code: 0 = No bleeding on probing 1 = Pockets <4mm & bleeding on probing 2 = Pockets <4mm, BOP & plaque retentive factors 3 = Pockets 4 & 5 mm 4 = Pockets at least 6mm * = Pocket recession at least 7mm in total: fucation involvement         BPE: 0 1 2 3 4 * 0 1 2 3 4 * 0 1 2 3 4 *       0 1 2 3 4 * 0 1 2 3 4 * 0 1 2 3 4 *     Dental Health Spa to take BPE?:         Are x-rays being sent?: no yes - x-rays to be posted yes - x-rays with patient     Dental Health Spa to take x-rays?         Specific observations:     Referral options:             Dental Health Spa appointment     Preferred date:     Preferred time: 08 09 10 11 12 13 14 15 16 17 18 19 00 30