Implant Referral Form

Name of referring Dental Surgeon

Name of referring Practice

Referring practice address

Referring practice telephone

Referring practice email

PATIENT name

PATIENT address

PATIENT telephone

PATIENT date of birth

PATIENT'S primary concern

PATIENT'S expected outcome

Would you like Gallions Reach to provide Prosthetic Care? Would you like Gallions Reach to provide Prosthetic Care? Yes No

Would you like to attend any stages of treatment and surgery? Would you like to attend any stages of treatment and surgery? Yes No

Objectives of Implant Treatment for this case Objectives of Implant Treatment for this case Single tooth replacement To retain fixed bridge To stabilise removable prothesis To retain complex full arch restoration

Please give details of any relevant information which may be of assistance

6 + 7 =

It may not be possible to place implants in certain positions due to factors such as insufficient bone or proximity to nerve canals. Usually with these cases bone augmentation can be carried out in conjunction with implant surgery.

Every patient that you refer to our clinic will receive a pre-consultation information pack that will help your patient understand the nature of the proposed treatment and give them a broad idea of the anticipated costs. Once they have received this pack, they should telephone the clinic so that a suitable consultation appointment can be arranged.

Study Models and Radiographs

It would be most helpful if you could send any available information, such as models and radiographs to us in advance or with the patient for their consultation with us. We will ensure that they are returned to you.

If you have any queries then please do not hesitate to contact us: 020 8312 3363

If you would prefer to print off or download a PDF version of this form you can do so by clicking the button below:

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Implant Referral Form

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