Implant Referral

Dentists please complete the form below if you wish to refer patients to Ipswich Dental Care for implant placement(s).

We will reply to your request as soon as we can.

Your Practice Details

Practice Name

Practice Address

Practice Email

Practice Telephone

Patient Details

Title

Full Name

Address

Postcode

Date of Birth

Telephone

Mobile

Treatment Required

(Please indicate in which area(s) treatment is required, for fees refer to website)

Single Implant Implant Retained Bridge Implant Retained Denture All-on-four concept

Please give specific details of the area(s) requiring treatment *

Short summary of the case *

Medical History

Radiographs Included

YES NO

Attach Radiograph (file types accepted gif/png/jpeg) File name to include referring dentist name, patient initials and patient DOB.

File Upload

OPG Bite wings Peri-Apical CBCT

Will the patient benefit from sedation

YES NO

Is your patient a regular attender to the hygienist?

YES NO

Frequency of hygiene attendance

Never 1 per year 2 per year 3 per year 4 per year

Referring Dentist Details

This will act as the practitioner’s electronic signature: I hereby authorize Ipswich Dental Care to carry out an implant consultation as outlined above.

Referring Practitioner

GDC Reg No *

Additional Comments

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Home
About Us
Dental Treatments
Nervous Patients
Blog
Contact Us

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info@ipswichdentalcare.co.uk