Referral forms for dental implant and cosmetic treatment

Patient Details

• Patient Name:
• Date of Birth:
• Patient Email:
• Patient Address:
• Patient Telephone (Work):
• Patient Telephone (Home):
• Patient Telephone (Mobile):
• The patient is experiencing:
  (Please tick)
  Failed Crown/Bridgework
  Periodontal Problems
  TMJ Problems
  Loose Dentures
  Social Problems Difficulty Chewing
  Poor Aesthetics
  Loose Teeth
  Failed Crown
  Any other problems

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Teeth Requiring Treatment

• Please specify problems:
• Brief History (about this referral):
• Please add any other information you think may be helpful:
• Upper:

  18	17	16	15	14	13	12	11

  21	22	23	24	25	26	27	28

  Lower:

  48	47	46	45	44	43	42	41

  31	32	33	34	35	36	37	38

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Practice Details

* indicates a required field.

• Referring Practice*:
• Referring Dentist*:
• Practice Email*:
• Practice Address*:
• Practice Telephone:
• Nature of treatment to be carried out by Cleveland CDIC:
  (Please tick)
  All treatment requested by patient
  Cosmetic treatment only
  Smile Makeover All Implant treatment
  Implant surgery only

Additional Information

• Patients knowledge of treatment required: Please Choose... Low Medium High
• Patient aware of level of investment required: Please Choose... Yes No
• Would you like to attend the patients visit: Please Choose... Yes No

Radiographs & Clinical Photographs

If you would like to attach any radiographs, clinical photographs or any documents that you feel would be of use, please use the upload facility below.

• Upload 1:
• Upload 2:
• Upload 3:
• Upload 4: