01242 655554

Patient Referral Form for dentists and doctors

Essential information for first-time users

If this is the first time you are using our patient referral form, please click ‘key info’ below to view privacy and referral guarantee information.
If you require any further information about referral service or assistance completing this form, please call 01242 655554 and speak to a team member.
And finally, if you prefer to download and complete a print version of our form, CLICK HERE.

Click here for key information about the referral service

Referral Guarantee

We value your trust in us to provide your patients with the best possible referral treatment and care.

To pledge our commitment to this, we have written a referral guarantee that puts your interests and that of your patients first.

To view, click referral guarantee in the sidebar

Data Protection

The information you provide here will be used solely to refer your patient to Arnica Dental Care. A patient record will be created within our secure patient management system, and a copy of this form will be scanned and added to patient notes.

WE WILL NOT share any information provided by you with any third party unless explicitly requested to do so in writing either by you – the referring GDP/GMC, or the patient.

For more information about how we protect your data and that of your patients, please see
our Privacy Notice on our website www.arnicadentalcare.co.uk/privacy-notice.

What Happens Next

You will receive a copy of this completed form via email on submission. Please keep it for your records

A member of the Arnica team will then contact your patient to arrange an appointment.

You will be notified of the appointment date and time.

You will be notified when treatment is complete


To ensure that the occasional technical glitch does not catch us out if a member of the Arnica team has not contacted you within 48 hours (2 working days) of completing this form, please call us on 01242 655554

Notice for Patients

Please note failure by the patient to attend the appointment will incur a £50 non-attendance fee.