Referral of a patient by their GDP for an Implant Consultation

If you would like to refer your patient for a consultation for implant work with our specialist dentist, please complete the form below, attach any relevant radiographs, and a member of our team will be in contact with the patient directly. Thank you in advance.

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* 1. Please provide us with the details below:

Name

Email Address

Phone Number

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* 2. Medical History - including all medications and any known allergies:

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* 3. Referring Clinician:

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* 4. Referring Practice Name:

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* 5. Clinical summary:

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* 6. Do you want us to undertake the patient's routine dental care as well as any implant work, or are do you wish to undertake all routine dental care for this patient?