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Dentist Referral
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2020-07-11T00:19:37+00:00
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*Name
Address
*Phone Number
Med Hx
DOB
*Email
*Mobile Number
Dental Implantology
Teeth replacement site(s)
Full arch implant reconstruction
Denture stabilisation with implants
Bone grafting/sinus elevation
Extraction with view to implant (atraumatic &/ or ridge preservation)
Guided Surgery
None
Cosmetic / Full Mouth
Reconstruction
Teeth in 1 day
Veneers
Crowns
None
Oral (Dento-alveolar) Surgery
Wisdom Teeth Management
Tooth/root removal
Gingivectomy/crown lengthening
Correction of gingival recession (gingival graft)
Apicectomy
Repair of oro-antral fistula/sinus exposure
Pre-prosthetic surgery (frenectomy/reduction of flabby ridge/other)
None
Sleep (IV Sedation) Dentistry)
Treatment required
Special needs or comments
None
Prosthetics
Please carry out both surgical and prosthetic phases of restoration
None
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Referring Dentist
*Dentist Phone Number
Special Needs
Note/Comments
Address
*Email
Medical History
Comments
Radiographs enclosed:
PA
OPG
Cone Beam
CT
DICOM discs
None
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Date
All information provided in this form is treated as Private and Confidential and will not be released to any party other than Dental Facial Clinic for the purpose of patient management.
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