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Implant Referral

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    Referring Dentist Details

  • Patient Details

  • Teeth / Areas to be treated

      Upper Left

      Upper Right

      Lower Left

      Lower Right

    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

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    Yes

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01792 476 714
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65 Walter Road, Swansea, SA1 4PT