Polygon Dental

Tel: 023 8039 0090
Email: info@polygondental.co.uk

1 Kenilworth Road, Polygon, Southampton SO15 2GD

I am A Dentist

Implant Referral Form

    Patient Details

    Address

    Contact Phone Numbers & Email Address

    Referring Dentist Details

    Practice Name, Address & Telephone Number

    Treatment Required

    Medical History

    Site: (please indicate)

    Upper Right

    Upper Left

    Lower Right

    Lower Left

    If referring due to recent XLA, when was XLA apt:

    Radiographs/OPG Taken (please include relevant radiographs):

    Regular dental visits (3/12, 6/12, 12/12):

    Last hygiene apt:

    Last 2 BPE Scores:

    Implant referral criteria/extra information

    • Please ensure all forms come with an up to date medical history (bisphosphonates, blood thinners, etc)
    • In some cases, implants can be placed immediately after extraction, please consider this before any extraction to preserve as much bone as possible.
    • Please attach relevant radiographs (for preimplant assessment, a periapical radiograph or an OPG would be required)

    Please ensure Patients have no active periodontitis.