Dentalcare PlusLondon Dental Implant Centre

Dental Implants and Cosmetic Dentistry in the UK

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REFERRALS

The clinic offers a range of surgical procedures required in the most complicated of implantology cases. These include: Sinus Lifts (Window and Osteotome), Block Grafts (Ramus/Chin), Guided Bone Regeneration and Soft Tissue Grafting. The clinic also offers a CT scanning service, Implant Assessments, Placement and Restoration; also Implant Placement with refer-back for restoration.


Dentist Referral Form for CT Scans, Implants & Oral Surgery

Fields with an asterisk* must be completed.
Referring Dentist's Name *
GDC No.
Practice Name *
Practice Address *
Postcode
Practice e-mail *
Practice Telephone *
Practice Fax No

PATIENT DETAILS

Patient's Name *
Patient's DOB *
Patient's Address
Patient's Tel
Patient's Email *
Patient's Mobile
Is this referral urgent?   Yes   No
   

Please indicate REASON FOR REFERRAL

FEE

 Comments/Region
  CT Scan £125.00
Implant Assessment with CT Scan £200.00
Sinus Lift Assessment with CT Scan £150.00
CT Scan & Radiology Report £300.00
   

Please indicate OTHER REASON FOR REFERRAL

   Comments/Region
  Implant assessment, placement & restoration
  Implant placement & refer back for restoration
  Full mouth reconstruction
  Sinus lift(s)
  Guided bone regeneration
  Block bone grafting
  Soft tissue grafting
  Alveolar ridge splitting
  Extraction & socket preservation
  Impacted tooth extraction
  Other
Additional Notes
 
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