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Streatfield Dental Surgery

206 Streatfield Road, Middlesex, Harrow HA3 9BU

 0208 204 9485

Open on Saturdays and evening by appointment


Patient Referral Form


Dear colleague, please use the form below to refer us Private PERIO, ENDO & IMPLANT cases. Please be clear and concise and please be reminded your patients will be charged a consultation fee as per fee guide. In cases where adequate information is provided by the referring GDP patients on payment of a suitable deposit may be booked in directly for treatment at the practices discretion and the consultation fee will be waived. Also, rest assured that on completion of any appropriate treatment your patients will be promptly returned to your continual care. Many thanks for your referral.


Any detailed information of patient or file attachments can be emailed to us at


Referring Dentist / Practice Name

Referring Dentist Telephone

Referring Dentist Email

Referring Dentist Address

Patient Name

Patient address and Telephone

Medical History of Patient

Treatment Required

Please tick how you would like us to contact you regarding your dental care via:    Email    SMS    Letter

Please tick for us to enable to send promotional material relevant to your dental care via:    Email    SMS    Letter

  I understand the practice will hold all my personal data securely in compliance with GDPR May 2018 and it will only be accessible to authorised members of staff: