ROI Patients
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South Down Dental Clinic

Implant Referral Form

Implant Referral Form

Personal Details

Do you smoke? *
50
Do you consume alcohol? *
50
How much weekly? (1 unit=1/2 pint of beer, 1 glass of wine, 1 measure of spirit)

Medical History - Private and Confidential

Do you have a medical history? *

Missing Teeth

Are you missing teeth from your upper jaw? *
Are you missing teeth from your lower jaw? *
Are you wearing dentures? *
Do you have any bridges? *

General Assessment of Dental Health

Are you aware of any other problems with your teeth *
Oral hygiene *
Do you have signs of gum disease? Bleeding Gums? *
Do you visit your dentist/hygienist regularly? *
Toothwear? *
Do you require any fillings? *

Upload a picture of your teeth

If possible please attach a picture of your teeth

Maximum file size: 67.11MB

Confirmation

Checkboxes *