Self Referral You do not need a letter of referral from your Dentist to see one of our Orthodontists for an assessment. Private assessments for children and adults can be arranged at a time that is more convenient to you. The fee for a Private Consultation is £75. This fee includes radiographs and study casts, if they are needed, and a written report for you and your dentist. Please complete the form below and then click on the Submit button and one of our team will then contact you to arrange your first appointment.   Patient's Name: Patient's date of birth * Parent's Full Name (if Child): * Home Telephone No: Home Address: Postcode: Work Telephone No: * Email Address: * NHS or Private : NHS Private Current Dentist : On what day would you like to see us?: At what time would you like you appointment?: Which practice would you like to visit?: Which practice south east west north (Other) What is the main problem with your teeth that we may be able to sort out for you?: How did you find out about our website?:     Please keep this box ticked if you wish to be added to our mailing list

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