Patient Details

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      • Referring Dentist Details

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    • Reason for Referral

      Fixed Prosthodontics / Restorative Dentistry

      Removable Prosthodontics

      Endodontics

      Oral & Maxillofacial Surgery

    • Implant Dentistry

      Implant Placement

      Implant Placement & Restoration

      Bone / Sinus Grafting

      Peri Implantitis / Complications

    • Please tick one of the following:

      I would like a report and advice with this case

      I would like you to carry out the following treatment and return the patient back to our practice

      I would like you to treat as you see necessary and let me know of your plan for this case

      Should you wish to discuss this case with one of our specialists, please call us on 01865 256007

    • Further Details

    • Medical History

    • Attached Files

    • What are the Attached Files

      Radiographs

      Photos

      Other (please specify)

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