Dentist Referral Form

Please complete the form as fully as possible, ensuring that all fields in the Practice Details and Patient Details sections are completed. When done, please click the Submit button to send the details to us. Once submitted you will be able to print the completed form for your records.

Practice Details

Referring practice *

Practice address *

Referring dentist *

Tel *

Email *

Patient Details

Patient name *

Patient address *

Date of birth *

Tel *

Mobile *

Email *

Is referral urgent? * Yes No

Referral Information (please tick all relevant boxes)

Reasons for referral:

Opinion only

Single tooth missing

Totally edentulous jaw(s)

Multiple teeth missing

Full mouth rehabilitation

Cosmetic

Affected areas:

Upper Lower Both

Types of implant retained restoration which have been explained to the patient:

Single tooth implant

Implant & tooth retained bridge

Partial overdenture

Full restorative case incl. perio, prostho & implants

Implant supported bridge

Hybrid prosthesis

Full overdenture

Teeth-in-an-hour ™

Is your request for implant placement only?

Yes No

Has the patient been made aware of the level of investment that may be required?

Yes No

Brief History (comments about this referral)

Diagnostic Aids (please tick all relevant boxes)

In order to minimise unnecessary exposure please indicate which radiographs you are sending with the referral:

OPG

PAs

Other radiographs

For more complex cases please indicate that study models will accompany the patient for the initial consultation:

Yes No

Please be assured that we will neither approach nor accept your patient for non-referred treatment.

Dr R J Anderson BDS LDS RCS (Eng) MMedSci | Dr K Ruiz BMed Sci MB ChB FRCA
Tel: 0845 467 5268