1st Floor, 3 Nottingham Street, Melton Mowbray, Leicestershire, LE13 1NN

Online Specialist Referral Form

At Melton Orthodontics, we are pleased to accept referrals from dental practices throughout the UK for all types of orthodontic procedures.

If you are a dentist and would like to refer an orthodontic patient to us, simply complete the form below online and a member of our team will arrange an appointment for your patient and notify them by post. Please be sure to include your reason for referral. Alternatively, you can download the Specialist Dental Referral Form - pdf version, by clicking here and post it to us, enclosing any x-rays, covering letters or further necessary information.

  Download Specialist Referral Form as PDF

Specialist Referral Form

Patient Details
Referring Dentist Details
Further Information
Clinical Information - please tick one or more or provide IOTN
Referral Requirements
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Site last updated 25.04.2018