Referrals - Langley's Dental Centre

At Langley’s Dental Care we passionately believe in providing your patients with the best that modern care can offer. We understand that your patients are all unique with different needs, concerns and requirements and so we tailor-make all our advice and guidance to each individual.

Meet our Specialists

Dr Sharan Gill

Specialist in Orthodontics

MOrth Royal College of Surgeons of Edinburgh 2007, MFDS Royal College of Surgeons Of England 2004, MFDS Royal College of Surgeons of Edinburgh 2003, BDS Lond 2000
GDC NO: 78272

Dr Alaa Gunni

Specialist in Periodontics

BDS Hons (Lond) MFDS RCS (Ed) PG Cert (Perio) MClinDent Perio (Hons) MPerio RCS(Eng)
GDC NO: 251133

Referral Form

Patient Details

* Indicates required field

Patient's Title *

Patient's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Patient's DoB *

day/month/year

Patient's Gender *

Patient's Email *

Patient's Mobile Number *

Patient's Home Phone Number

Referring Practitioner

Practitioner's Name *

First

Last

Practitioner's GDC Number *

Practitioner's Phone Number *

Practitioner's Email *

Referring Practice *

Practice Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Referral Details

Reason for Referral *

Periodontics
Orthodontics

Observations and Dental History *

Please add as much relevant clinical history information as possible,.

Medical History *

Please add as much relevant medical history as possible, in particular significant conditions, allergies or medications.

Upload Any Reference Documents

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Accepted file types: jpg, pdf, png. Max. file size: 64 MB, Max. files: 10

Patient's consent *

Tick box to confirm that the patient's consent has been received to sending their details.

GDPR consent *

By submitting the above information, you are confirming that you have read and agree to the Privacy Policy and that you consent to us contacting you by phone or e-mail regarding your referral.

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