Self Referral Form

Please fill in the self referral form below so we can understand your needs and make contact with you.

Your Details

Title

Name*

Patient Date of Birth*

Address*

Phone (Day)

Phone (Evening)

Patient Email*

Preferred Method of Contact

Phone

Dentist Name (If Applicable)

Dentist Address (If Applicable)

Services Required*

Hygiene

Endodontics

Periodontics

Implants

Attach relevant image or radiograph

Up to 9mb files only

* I consent to Alpha House storing my patient's data for this referral (required)

By submitting this form you understand that your data is processed in accordance with our privacy policy.

Please input reCAPTCHA above

Positive: caring, knowledgeable and extremely helpful

I have been a patient at Alpha House for a number of years now and the switch to this practice has been the best thing I have done regarding my teeth. The service and treatment I have received has been second to none. Everyone from the Dentists, Specialists, Hygienists, Dental Nurses and Reception Staff are all caring, knowledgeable and extremely helpful. I now have no hesitation in going to the Dentist, where as previously I always felt anxious about going. I feel comfortable attending and am reassured every step of the way. I have no hesitation in recommending Alpha House to anyone who like me gets anxious about attending the Dentist.

Mr OS