Implant Referral Form - Horfield Dental Care

Click here if you’d prefer to print the form and send it to us via post.

Please ensure any Radiograph images are encased in the envelope.

Implant referral form NEW

Fields marked with an * are required

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Referring Dentist

Practice name *

Dentist name *

Telephone number *

Address

Postal code

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Patient Details

Title *

Name *

Date of birth

Telephone number

Address

Postal code

Does the patient have any Medical Conditions?

If YES please list below:

Is the patient taking any medications? *

If YES please list below:

Does the patient have any allergies?

If YES please specify below:

Implants : Please provide brief details of treatment required

Would you like us to restore the implant too? *

Other treatment required:

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Please provide radiographs where available

Radiograph #1

Radiograph #1 Copy

Radiograph #1 Copy Copy

If no please specify reason:

Date/Time *

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