Patient Referral

If you would like to refer a patient to us for Specialist Periodontal or Dental Implant treatment please fill in the form below or print out the PDF version and post it to us.

We are very flexible with our referral Dentist’s and are happy to provide as little or as much input as required. For example, if you would like us to provide comprehensive implant treatment involving bone grafting, implant placement and restoration then we will be happy to do so. However, if you wish to restore the implants yourself we can help by just placing the implants and then referring the patient back to yourself when the implants are integrated and ready to restore.

We also encourage referring Dentists to come along and observe the treatment of their patients to gain an insight into dental implant treatment in particular. If you are new to dental implants then watching your patient having their implants placed and restored is a wonderful way to start understanding this increasingly common treatment option.

If you feel encouraged to take things further you may wish to consider taking part in one of our Training Courses or consider being Mentored by Dr Roberts.

Referral Form

Please complete all required fields marked*

Referring Dentist Contact Details

Dentist Name*

Dentist Email*

Dentist Practice Address

Practice Postcode

Practice Telephone Number *

Dentist Mobile Telephone Number

Patient Contact Details

Patient Name*

Patient Address*

Patient Postcode*

Patient Date Of Birth*

Patient Telephone Number(s)*

Patient Email Address

Reason For Referral

If your patient is being referred for implant treatment please specify how much input you require from us e.g. assessment and implant placement or implant placement and restoration etc.

Referral Details

Additional Information

Relevant Medical History

Any Other Important Information

Attach Any Relevant Digital Radiographs Here:
Please attach files as JPEGs (file size no greater than 4MB) or post traditional films

Please Tick The Captcha Box Below Before Submitting - Thank You!

An email containing the information above will be sent straight back to you so that you have a copy for your records.

required fields marked *
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Patient Referral

Referral Form

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