Implant Referral

Referring Dentist Details

Name:

Practice:

Address:

Tel:

Email:

Patient Details

Name:

Date of birth:

Address:

Tel:

Email:

Teeth / Areas to be treated

Upper Left

• 8
• 7
• 6
• 5
• 4
• 3
• 2
• 1

Upper Right

• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8

Lower Left

• 8
• 7
• 6
• 5
• 4
• 3
• 2
• 1

Lower Right

• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8

Implant Referrals

Level of Referral

Assessment and treatment plan only:

Implant Placement and Refer Back for Restoration:

Bone Graft/Sinus Lift and Refer Back to Clinician:

Implant Assessment, Placement and Restoration:

 

Treatment Required / Discussed

Single Implant Supported Crown:

Implant Supported Bridgework:

Implant Supported Denture:

Full Multidisciplinary Restorative Case:

Oral Surgery Referrals & Enclosures

• Relevant Medical History:
• Relevant Medical History:
Would you like to attend for surgery with your patient?
No
Yes

I’d like to be informed of exclusive offers and other practice information YES

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