call us now on 01622 751553

call us now on 01622 751553

REFERRAL FORM

Dental implant referral form

If you have any queries then please do not hesitate to contact us on 01622 751553

Referring Dentist
Name*
Prefix First Last
Practice Name*
Practice Address
Street Address Address Line 2 City County Postcode
Phone*
Email*
Patient Details
Patient Name*
Prefix First Last
Patient Address
Street Address Address Line 2 City County Postcode
Patient Contact Number*
Patient Email*
Patient Date of Birth*
DD slash MM slash YYYY
Patient's Primary Concern
Patient's Expected Outcome
Further Details
Would you like The Implant Experts to provide Prosthetic Care?*
- Yes
- No
Would you like to attend any stages of treatment and surgery?*
- Yes
- No
What are the treatment objectives ?
- Single tooth replacement
- To retain fixed bridge
- To stabilise removable prothesis
- To retain complex full arch restoration
Please give details of any relevant information which may be of assistance
X-ray image upload
Drop files here or

Max. file size: 128 MB.
We'll keep in touch with you regarding any courses and events we may hold, which we think you will find useful.

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Download a paper version

If you would prefer to fill the form in by hand you can download a pdf by clicking on the link above. Please send it to:

The Implant Experts
3 Ashford Road
Maidstone
Kent
ME14 5BJ

CONTACT INFORMATION:

01622 751553

3 Ashford Road
Maidstone
Kent
ME14 5BJ

The Implant Experts

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GENERAL INFORMATION:

Opening hours:
Monday - Friday 08.45 - 17.15

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