Dentist Referrals
Refer Your Patient for CT Scanning, Dental Implants and related treatments. Either Fill-in Form Below, Call 010 76300782

THE LONDON DENTAL STUDIO REFERRAL FORM

Fill-in the following form and click on the “Submit” button to send your referral request.

REFERRAL DETAILS

(Please tick required treatments)

 

Dental/Mini Implants
Bone/Sinus Grafting
Nerve Repositioning
CT Scanning

 

Or please contact this patient:

Preferred Contact Method:

ATTACH/SEND US A FILE HERE (Please Tick) 10MB MAX:

Upload Medical History Sheet:
Upload X-Rays Here:
Upload Casts Here:
Upload Photos Here:
Upload CT Scan Here:

 

TREATMENT REQUEST DETAILS

 

The patient requires an urgent Implant appointment:

YesNo

Implant type requested:

Conventional Dental ImplantsMini ImplantsOther Implants


Bone GraftingSinus Grafting



 
CT SCANNING

The patient requires an urgent CT Scan:

YesNo

Radiographic Marks for Patient?

YesNo

MaxillaMandible

Service/Payment Code (see price list):

Payment:

Client AccountPatient Pay LD

 

PATIENT DETAILS

Note: (For Rheumatic fever/ Heart valve defects please ensure the patient takes appropriate antibiotic cover prior to the appointment.)

 

Sex:

MF

 

Patient's Date of birth:


Patient's Email Address:

Patient's Telephone Number:

Patient's Mobile Number:




 

REFERRING DENTAL PRACTICE DETAILS

 

Dentist's Name:

Dentist's Email Address:

Dentist's Telephone Number:

Dentist's Mobile Number:

Dentist's Fax:


GDC Reg. No.: