Invisalign Referral Form

Name of the Patient*

First NameLast Name

Patient’s Date of Birth*

MonthDayYear

Patient’s Gender*

Patient’s Phone:*

Area CodePhone Number

Patient’s E-mail*

example@example.com

Patient’s Address:*

Home Name/Number

Street Address

Town/CityCounty

Post Code

Marital Status

Type of Referral*

Urgent (needs consult within the week)Routine (needs consult within 2 weeks)Review (previous patient)

Medical History*

Health Status*

1 Healthy2 Mild Medical Condition3 Multiple Medical Conditions4 Life-threatening Conditions

Taking any medications, currently?*

YesNo

If yes, please list it here:

Chief Complaint*

Reason for Referral*

IOTN

Dental Component + Aesthetic Component

Treatment Required:*

Please list treatments required etc.

Does Patient have an OPG?*

YesNo

Would you like us to do an OPG xray?

YesNo

File Upload

Please upload OPG (annotated with name, DOB and date taken).

Clinic Name:*

Referrer’s Name:*

First NameLast Name

GDC no.*

Phone:*

Area CodePhone Number

E-mail*

example@example.com

Clinic Address:*

Street Address

Street Address Line 2

Town/CityCounty

Post Code

Please verify that you are human*

Treatments Tariff

(Please advise the patient of the fees before submitting this referral form)

Consultation includes Clinical photographs, Scans, Base charting, and treatment planning - £95

OPG (Big Xray) - £55

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INVISALIGN TARIFF

Invisalign Comprehensive (5 years) unlimited aligners - dual arch £5850

Invisalign Comprehensive (3 years) unlimited aligners - dual arch £5350

Invisalign Moderate (2 years) 20 aligners - dual arch £4850

Invisalign Lite (2 years) 14 aligners - dual arch £4350

Invisalign Express (1 year) 7 aligners - dual arch £3850

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RETAINERS

Lingual-bonded retainer - £155 each

Clear Essix retainer - £100 each