For dentists

Dentist referrals.

Refer a patient for specialist orthodontic care at Portman Smile Clinic Banstead. Complete the form below and our team will follow up with your patient as soon as possible.

Refer with confidence

Whether it’s Invisalign®, braces or an orthodontic assessment, your patient will be in expert hands with our Specialist Orthodontist, Dr Massod Mousavi. We’ll keep you informed throughout their treatment and return your patient to your care once it’s complete.

Questions about a referral? Call us on 01737 405 123.

Referral form

Please complete all required fields.

Referring dentist

First nameLast name

EmailPhone

GDC number (optional)

Referring practicePractice nameStreet address

Town / cityPostcode

Patient details

First nameLast name

EmailPhone

Date of birth

Address line 1

Town / cityPostcode

Clinical notes / reason for referral

Please don’t attach X-rays or scans here. Bring any recent imaging to the appointment, or send it to the practice directly.