Implant Referral Form
Please fill in the following form to refer a patient to our practice for an implant. You as the referrer will be kept updated on the patient's progress and will receive a discharge form.
You will be emailed a copy of this form instantly and the patient will be contacted and booked in as soon as possible.
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What's the Patient's full name? *

 
What is {{answer_13360319}}'s Address please?

 
What is the patient's Date Of Birth?

 
What is the patient's Mobile (or Home) Number?

Please add as many numbers as you wish!
 
Any relevant medical history?

 
Is there a possibility the patient is pregnant?

     
 
Which site(s) are you referring the patient for implants to be placed in?

Please be as specific as possible. e.g. UL6. or replacing all upper teeth.
 
Is an extraction required?

     
 
Do you wish to restore the implants?

This is only for referring dentists who have completed an appropriate training platform for restoring implants and have attained relevant competancy to provide long term success. This can be provided at our practice on one of our many study evenings.
     
 
Are you sending any pre-operative radiographs?

Please send in a digital format to our email address email@dentistontherock.com
     
 
The patient will be charged £45 plus radiographs for an assessment which will determine whether implant placement is possible. Is the patient aware of this?

     
 
What's the referring Dentist's full name? *

 
What is {{answer_13360322}}'s Practice Name & Address please?

 
Terms & Conditions - Please type you name at the end of reading the following to confirm you have read and agree to abide by the following terms. Referrals will not be accepted without a practitioners approval. *

Disclaimer: 
We endeavour to provide the very highest quality results, however, we will not accept any liability for incorrect or incomplete information on the Referral Form, or inappropriate or inadequate patient preparation or warning of fees.
We endeavour to despatch results of the assessment and the final discharge letter to the referring Dentist/Surgeon as fast as possible, however, equipment malfunction or pressure of other work may introduce delays. We reserve the right not to accept referrals in any case.
We will not accept any liability for consequential losses arising from delays whether because of late or non-payment, non-receipt of a Referral Form, pressure of other work, or for any other reason.
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