Excellence in Dental Implants
The Implant Studio,
41 South Bar Street,
Banbury OX16 9AE
01295 262008

Referral form

Digital panoromic referral details

Digital panoramic:
With TMJ
Without TMJ

CBCT examination referall details

Full arch:
Maxilla
Mandible

Imaging stent supplied by referring dentists:
Yes
No

Imaging stent required:
Yes
No

Small volume
Yes
No
If yes, please complete the tooth diagram below. If no teeth are selected the whole jaw will be scanned.

Patient details

Surname
Initials
Title
Date of birth
Address
Phone
Mobile
Email

Medical history

Upload radiograph PDF, JPG, PNG formats accepted
Not available/ I don't have one

Referring dentist's details

Referring practioner
Practice name
Address
Phone
Fax
Email

Purpose and proposed course of treatment

ENDO
IMPLANT
PERIO
Post op/Low dose
Other
Payment
Patient to pay
Account to referrer

Confirm and send

I confirm the above information is correct
international team for implantology logo
dentist of the year 2016
adi dental implantology
01295 262008
info@implantstudio.com
The Implant Studio
41 South Bar Street, Banbury OX16 9AE