Patient Referral Form

Dentist Details

Patient Details

Referral Details

Radiographs & Clinical Photographs

If you would like to attach any radiographs, clinical photographs or any documents that you feel would be of use, please use the upload facility below. (If you are attaching files it will take upto a minute to submit, once you have clicked submit please wait for the page to refresh, You can upload maximum of 4 files)

By using this form you agree with the storage and handling of your data by this website.

Book your initial consultation at Huddersfield’s favourite dental practice today!

Yes please, I would like a free tailored treatment plan

Get Started Now

Call Now 01484 714 640

Or ask us a question below and a member of our team will be in touch shortly. Alternatively why not upload photos of your teeth with a brief message and receive your own tailored treatment plan next working day.

Fresh Smile Clinic Google rviews