Dentist referral form

If you are looking to refer one of your dental patients for orthodontic treatment, please fill out the form below or download our patient referral form. We will work closely with you to ensure the healthiest smile possible for your patient.

 

Please fill in all fields marked with *

Practitioner details

Patient's details

Enclosures

Please send any enclosures to us via email info@smilelux.co.uk or by post.

By confirming your place you are agreeing to our privacy policy.

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Find us

SmileLux Specialist Orthodontic Centre
12 Whittle Court
Knowlhill
Milton Keynes
MK5 8FT

01908 398 068 Directions & Opening times