By submitting this form, you confirm the following:
- Your patient is aware that dental treatment will be provided by Dr. Shilpa Shah.
- All appointments will be held at Victoria Clinic, 109 Corporation St, Manchester, M4 4DX.
- Your patient consents to be contacted by Victoria Clinic to organise their appointments.
- You have provided a complete and accurate medical history and relevant radiographs.
Failure to accurately complete this form may lead to a delay or rejection of your referral.
Once your referral is submitted, a member of our team will contact the patient to organise an appointment.