If you are a practitioner and would like to refer one of your patients to us for treatment, simply complete the form below. Once submitted you will receive a confirmation email for your records and one of our treatment coordinators will contact the patient to arrange an appointment. For more information about the services we offer to help clinicians with diagnosing and treatment planning or if you have any difficulties with this form, please contact us. If you would prefer to print a hard copy of the referral form please click here for an NHS orthodontic referral form or click here for a Private Referral Form.



    Type of referral

    Your Details

    Your Patient's Details

    We take your privacy seriously and we will only use the details you provide to respond to your enquiry or in order to fulfil your request.

    We will never sell your data or share it with any third parties

    From time to time we would like to contact you with information about the services we offer as well as CPD peer review events that may be of interest to you. Please indicate if you are happy for Resolution to contact you via email for this purpose.

    If you wish to see what data we hold on you or wish to have your data deleted please email us on: mail@resolutionsmile.com