01772 458855
71 Dental, 71 Towngate, Leyland, Lancashire, PR25 2LR

Referrals

Referring a Patient to 71 Dental

Secure Online Referral Form

Submit your referral quickly and safely via our encrypted online referral form below.

Referral by Post

Download and complete our PDF referral form, then post it to:
71 Dental
71 Towngate
Leyland
PR25 2LR

Download PDF Referral Form

Need to Chat First?

If you'd like to talk through a potential referral, please don’t hesitate to get in touch.

Tegan and Jade are always happy to help and can arrange any further discussions with the appropriate clinician.

Referral Form

Services Required:


Dentist Details




Patient Details




Referral Case Information

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.
Maximum File Size 10MB



Once we receive a completed form, we will contact the patient to arrange an appointment. If the referral is from a dentist, we will also liaise with the referring practice.

If you’re referring yourself, we will only contact your dentist if you give us permission to do so.

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Site last updated Dec 2025
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