DENTAL IMPLANT REFERRAL - Broadwater Dental Clinic

Treatment required Treatment required Single Implant Implant Retained Bridge Implant Retained Denture All-on-four concept (Please indicate in which area(s) treatment is required)

File name to include referring dentist name, patients initials and patient DOB File InputNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, png. Max. file size: 1 MB

Will the patient benefit from sedation? Will the patient benefit from sedation? Yes No

Is your patient a regular attender to the hygienist? Is your patient a regular attender to the hygienist? Yes No

If 'yes', frequency of hygiene attendance? If 'yes', frequency of hygiene attendance? Never 1 per year 2 per year 3 per year 4 per year

Referring dentists details I have explained the need for referral and obtained my patient's consent for the treatment to be carried out.

Practitioner Authorisation and Responsibility Statement

I confirm that:

The patient has been examined by me and is dentally fit for implant assessment.
Periodontal health has been evaluated, and any required stabilization has been completed or is being managed.
All relevant clinical information provided is accurate to the best of my knowledge.

By submitting this referral, the referring dentist acknowledges that:

The practice will assess the patient and recommend treatment based on clinical findings and suitability.

Final treatment planning decisions rest with the treating dentist in accordance with professional standards.

The referring dentist retains responsibility for the patient’s routine dental care.

The practice accepts no liability for pre-existing dental conditions or incomplete information provided at the point of referral.

Implant Referral

Implant Referral Form

Practitioner Authorisation and Responsibility Statement