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39 Newnham Road • Cambridge • CB3 9EY
IMPORTANT NOTICE: In support of the national effort to curb the spread of COVID-19, we have decided to close our practice from Monday 23/03/2020 for all but emergency treatments and telephone advice. Please call the practice for details of the emergency service on 01223 461 381 or email us. All routine visits will be rescheduled once normal operations resume.

Referral

Referring Dentist

Patient consent has been received for this referral

Name:*

Address:

Postcode:

Tel:*

Email:*

Date:

Patient Details

Name:

Address:

Postcode:

Tel:

Email:

Date:

Is this referral urgent?
Yes
No

Relevant Medical History

(any additional comments about this referral)

Referral Details

  

Other Treatment Requested

File(s):





Please carry out any treatment necassary prior to implant placement
Please liase with referring practice for restorative treatment prior to implant placement