Referral Form | 30a Wimpole Street

Select a Specialist Service

Please either fill in the form below or send an email to [email protected],
providing information on both the patient you are referring and your dental practice.

step 1 of 4

Select a Specialist Service

Oral Surgery (Dr George Paolinelis)Orthodontics (Dr Heike Bornert)Implantology (Dr George Paolinelis)

step 2 of 4

Patient details

Date of birth

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Patient is aware of the referral and agree to be contact on the above details.

step 3 of 4

Referral’s details

Every referral patient will return to their original practice once treatment with our specialists is complete – unless otherwise requested.

During the treatment process, we will keep you informed about your patient’s progress. However, if you have any further questions, please do not hesitate
to get in touch with us.

step 4 of 4

Referral details

Oral Surgery (Dr George Paolinelis)Orthodontics (Dr Heike Bornert)

File Attachments*

Choose file