Dental Implant Referral Form

Referring Dentist
Name*
Prefix First Last
Practice Name*
Practice Address
Street Address Address Line 2 City County Postcode
Phone*
Email*
Patient Details
Patient Name*
Prefix First Last
Patient Address
Street Address Address Line 2 City County Postcode
Patient Contact Number*
Patient Email*
Patient Date of Birth*
DD slash MM slash YYYY
Patient's Primary Concern
Patient's Expected Outcome
Further Details
Would you like Gallions Dental to provide Prosthetic Care?*
- Yes
- No
Would you like to attend any stages of treatment and surgery?*
- Yes
- No
What are the treatment objectives ?
- 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
X-ray image upload
Max. file size: 64 MB.

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 1626

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

PDF version

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Dental Implant Referral Form

Referring Dentist

Patient Details

Further Details

Opening Hours