The Dental Implant Clinic | Online Referral

  • Practitioner's Details

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  • How would you like to be contacted?*

  • Patient's Details

  • Date of Birth*
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  • Request

  • Urgency*
  • Rows
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  • Further Treatment: (Please Tick) Our policy is to refer the patient back to you if we encounter any of the following during the assessment. Would you like us to proceed with the additional treatment?

  • Other requirements and complications

  • Periodontal disease

  • Rows
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  • Radiograph upload and submission

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  • If radiographs are not digital, they can be sent via post to: Treatment Co-ordinator, The Dental Implant Clinic, 24 Newbridge Road, Bath BA1 3JZ.

  • CBCT Scan Required
  • Radiologist Report Required?*
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