Clear Dental

Implant Referral Form

Referral Practice *

Referring Dentist Name *

Referring Dentist GDC Number *

and Score capacity

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

Click or drag files to this area 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. *

Cookie	Duration	Description
cookielawinfo-checbox-analytics	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checbox-others	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-performance	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.