Implant Referral

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

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

Your Practice Details (please ensure this section is fully completed)

* indicates required field

Patient Details

Treatment Required

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

Single ImplantImplant Retained BridgeImplant Retained DentureAll-on-four concept

Radiographs Included

YesNo

Attach Radiograph (file types accepted gif/png/jpeg)

File name to include referring dentist name, patient initials and patient DOB.

OPGBite wingsPeri-ApicalCBCT

Will the patient benefit from sedation

YesNo

Is your patient a regular attender to the hygienist?

YesNo

Frequency of hygiene attendance

Never1 per year2 per year3 per year4 per year

Referring Dentist Details

This will act as the practitioner’s electronic signature: I hereby authorize dentalessence to carry out an implant consultation as outlined above. (for any relevant fees please visit dentalessence.co.uk)

Dentist Referrals

We also provide the following services on a referral basis.
Please click on the links below for the individual referral forms.

CBCT Referral Form
Hygienist Referral Form
OPG Referral Form
Oral Surgery Referral Form