Patient details

Address

Postcode

Date of birth

Contact number

Email

Treatment required Treatment required Single Implant Implant Retained Bridge Implant Retained Denture All-on-four concept (Please indicate in which area(s) treatment is required)

Please give details of the area)s) requiring treatment

Short summery of the case

Medical history

Radiographs included Radiographs included Yes No

New Field New Field OPG Bite wings Peri-Apical CBCT

File name to include referring dentist name, patients initials and patient DOB File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, png. Max. file size: 1 MB

Will the patient benefit from sedation? Will the patient benefit from sedation? Yes No

Is your patient a regular attender to the hygienist? Is your patient a regular attender to the hygienist? Yes No

If 'yes', frequency of hygiene attendance? If 'yes', frequency of hygiene attendance? Never 1 per year 2 per year 3 per year 4 per year

Referring dentists details I have explained the need for referral and obtained my patient's consent for the treatment to be carried out.

GDC Reg No.

Practice name

Practice address

Postcode

Practice Email

Practice contact number

Additional comments