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T: 03302 233 958| hello@RBImplants.com

Dentist Referrals

We accept referrals via email, post or telephone. Please contact Louise on 07706 374 968 or email hello@rbimplants.com 

If you would like to observe or assist with the surgery or restoration, please contact Louise, or Richard on 07970 201114 or Richard@richardbrookshaw.com

Referral Form

PATIENT

Patient Full Name (required)

Patient Date of Birth (required)

Patient Address (required)

Patient Telephone Number (required)

Patient Mobile Number (required)

Patient Email (required)

REFERRING DENTIST

Name (required)

Practice Name (required)

Practice Address (required)

Practice Telephone Number (required)

Practice Email (required)

Referral Type (required)
Single ImplantMultiple ImplantsOverdenturesSinus GraftingAll-On-4UpperLowerZygoma

Referral For (required)
Implant Placement OnlyImplant Placement and Restoration

Treatment Required

Relevant Medical History

Diagnostic Aids (required)

To save time and prevent unnecessary exposure, please indicate which images are being sent with this referral:
OPGPA x-raysOther x-raysCT ScanClinical PhotosStudy Mods

Image(s) to be uploaded here (file size no bigger than 2MB)