Clear Dental

Implant Referral Form

Referral Practice *

Referring Dentist Name *

confirm BPE willing

Referring Dentist GDC Number *

Referring Practice Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Referring Practice Phone Number *

Referring Practice Email *

Confirm Email

Patient Full Name *

Patient Phone Number *

Patient Email Address *

Patient Date of Birth *

Patient Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Relevant Medical History *

Please include known allergies and current medications.

BPE Score

ALL cases with a BPE score of 4 require a 6-point pocket chart and plaque score attached to the referral. Please attach below.

BPE 6-pocket chart Sextant 1 *

BPE 6-pocket chart Sextant 2 *

BPE 6-pocket chart Sextant 3 *

BPE 6-pocket chart Sextant 4 *

BPE 6-pocket chart Sextant 5 *

BPE 6-pocket chart Sextant 6 *

Clinical History *

Please provide reason for referral. Attach all relevant radiographs and photographs below.

Is the patient a smoker? *

Radiograph Upload

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Description of images attached.

What treatment would you like carried out? *

I confirm that the patient has the capacity and is willing to make a voluntary and informed decision to consent to this referral being made and their information being share with Clear Dental. *

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