Referral into the Service

For professionals wanting to refer into our service, please use the following referral forms depending on your reasons for referring:

For every referral please compete the appropriate form

Special Care Clinics (form)

f your patients suffers from any of the following conditions, you will need to complete a supplementary form, listed below:

For Nervous and Anxious Patients use this the Pain and Anxiety form. However, if you are a Dentist, please use this Paint and Anxiety Dental form instead.

For Mental Health Patients please also complete the mental health form.

Please send all complete referral forms along with the supplementary forms to

If you are NOT sending this via a secure email address i.e. from to then please password protect your referral form and send the password in a separate email trail.

If you have any queries please call the Admin Team on 0114 3078571.

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