Implant Referrals Implantology Consultations carry a charge of £40 to the patient Patient name Patient address Patient postcode Patient date of birth Patient telephone Patient email Patient medical history Patient medication Smoking status SmokerNon Smoker Referring Dentist Name Referring Practice Referring Practice Address Referring Practice telephone Treatment Requested Contact email Attach Radiograph (if appropriate) 5mb limit per file. Jpg, Png or Pdf accepted Additional Radiographs Additional Radiographs Additional Radiographs Additional Radiographs
