Implant Referral – Lovat House Dental

This implant referral for is for Dr James Barber BDS, MJDF RCS (Eng), MSc (Dental Implantology). Dentist with Special Interest in Dental Implantology.

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- Patient Details
- Patient First Name*
- Patient Surname*
- Patient Address*
  Street Address Address Line 2 City Post Code
- Patient Email*
- Patient Phone Number*
- Patient Date of Birth*
  
  Day
  Month
  Year
- Patient Gender*
  - Male
  - Female
  - Other
- Referring Dentist's Details
- Name of Referring Dentist*
- Practice Name*
- Practice Address*
  Street Address Address Line 2 City ZIP / Postal Code
- Referring Dentist's Email Address*
- Referring Dentist's Phone Number
- Referral Details
- Treatment Requested*
  Detail diagnosis and details of consideration of other treatment options
- Medical History*
  All medical conditions, allergies/reactions and medications
- Other Information
  Please describe any mobility or communication issues relevant to the patient’s treatment
- Radiographs
  To prevent unnecessary re-exposure to ionising radiation, please enclose any appropriate radiographs with your referral. Radiographs must be labelled with the patient name, date of birth and date of exposure. Digital radiographs can be sent on CD or uploaded with this form.
- Radiographs included?
  - Yes
  - No
  - N/A
- File Attachment
  Please include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF
  Drop files here or
  
  Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 512 MB.
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Implant Referral Form - Dr James Barber

Patient Details

Referring Dentist's Details

Referral Details

Radiographs

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