Excellence in Dental Implants
Patients referrals
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The Implant Studio,
41 South Bar Street,
Banbury OX16 9AE
01295 262008
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Dentist of the Year 2016

Patient Referrals

We work regularly with external dental practices and hospitals to provide our dedicated dental implant skills. If you would like to be referred to The Implant Studio, please complete the form below. Alternatively, you can download a PDF version here to complete by hand and post/email to us.

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
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dentist of the year 2016
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01295 262008
info@implantstudio.com
The Implant Studio
41 South Bar Street, Banbury OX16 9AE