Referrals: Leicester orthodontist, thurmaston orthodontist: Manor Orthodontics in Leicester, Leicestershire (Leics): invisible braces, brace, orthodontics: orthodontist Leicester, orthodontist thurmaston, orthodontist leics


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Dentist referral

Dentists: please make a referral by completing the form below. You will receive an acknowledgment by return, and we will contact your patient to arrange a first appointment.

Private Fees: Children under 16:
Full case Assessment & Treatment Planning Appointments - £80
Fixed price children’s ortho - £1,800 (simple cases cost less)

Adults:
Consultation - £50
Full Case Assessment & Treatment Planning - £80
Treatment costs to be agreed with patient after treatment planning

* required fields


	Patient details

	Is your referral NHS or Private:*
		Private NHS
	Email address:
	Title:*
	Name:*
	Tel No:*
	DOB:*
	Sex:*
	Address:*
	Postcode:*

	Have we treated / do we treat another family member?:*
		No Yes
	Has patient been seen by another orthodontist?:* (A second opinion or continuation of treatment is only offered on a private basis)
		No Yes
	Dentist details


	Dentist's name:*
	Dentist's address:*
	Postcode:*
	Tel no:*
	Email address:*


	Reason for referral


	Your comments
		We recommend that you print this screen for your records prior to clicking the SUBMIT button.

Manor Orthodontics
Howard Watkinson & Sue Straw
2 Manor Road
Thurmaston
Leicester
LE4 8AG

T: 0116 266 1470
E: info@manor-orthodontics.co.uk