Hygiene Referral Form

Please fill in the form below for your patient's hygiene needs.

Patient Details

Patient Title

Patient Name*

Patient Address*

Patient Date of Birth*

Patient Phone (Day)

Patient Phone (Evening)

Patient Email*

Preferred Method of Contact*

Phone

Referring Dentist Details (If Applicable)

Dentist Name (If Applicable)

Dentist Address

Dentist Phone

Signed (please input full name and title)*

Date

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

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I was absolutely terrified of dentists in general before visiting the Alpha House Dental Practice - I would physically shake with fear. Unfortunately I developed a painful abscess and looked for a local dental surgery to me. All I can say is that I feel so lucky to be a patient of the Alpha House Dental Surgery. Mr Hussain is a wonderful dentist - caring, gentle and understanding.

He understood my fears and did his best to put me at ease. The whole team at Alpha House are excellent, second to none, and all are extremely caring and kind. For anyone with a fear of dentists please go and visit Alpha House to see Mr Hussain and his lovely team. It doesn't feel like any dental surgery I have ever visited before. You really will be in the safest hands. Thank you to you all!
We were most impressed by the way in which you and your team handled every aspect of the job down to keeping our 2 year old son entertained it made the whole thing a pleasurable experience.