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Appletree Dental Referrals

Home » For Dentists

Download PDF version by clicking here.

Dentist

Implant Dentist: Conor McEnhill

Referring Practitioner

1. Name:*
2. Practice Name:*
3. Telephone:

Patient Details

1. Treatment Type:* NHS Private
2. Title:
3. First Name:*
4. Surname:*
5. Date of Birth: (dd/mm/yyyy)
6. Address 1:
7. Address 2:
8. Town:
9. Postcode:
10. Tel (daytime):
11. Tel (evening):
12. Mobile:
13. Email:
14. CHI:
15. NHS No:

Treatment Required

Implant treatment required	Single tooth replacement
	Fixed bridge
	Overdenture
	Bone grafting
	Do you wish to restore the implant? yes no
	Other (please specify):
Other procedures	Apicectomy
	Biopsy
	Orthodontic exposure/bond
	Hard tissue
	Fraenectomy
	Pre-prosthetic surgery
Patient's main complaint:
Relevant medical history:
Other relevant information:

Extraction

1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16
32	31	30	29	28	27	26	25	24	23	22	21	20	19	18	17
A	B	C	D	E	F	G	H	I	J
T	S	R	Q	P	O	N	M	L	K

Please Verify Tooth Numbers:

Email Copy

We can send you a copy of the details you complete in this form for your own records.

1. Please email me a copy of these details
2. Email address:

Digital Radiograph

Radiograph -select- Posted Given To Patient Please Take No X-Ray Uploaded below

You may upload a patient's digital radiograph using this form. Please upload images of type JPG, GIF or PNG only with a maximum file size of 2MB.

Digital Radiograph

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048 3025 2228 (ROI)
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