Dental Referral

If you are a dentist and would like to refer a patient to The Implant Foundation, please Call us on 0191 284 5666 - or, if you prefer, you may complete the proforma below and we will contact the patient directly.

Surgeon

Surgeon name *

Address *

Postcode *

Email *

Telephone *

Fax *

Patient

Patient name *

Address *

Postcode *

Telephone *

DOB (dd/mm/yy) *

Main concern *

Reason for referral *

X-rays will be forwarded to The Implant Foundation:

By email to: info@implantfoundation.co.uk

By Post to:
The Implant Foundation,
77 Elmfield Road,
Gosforth,
Newcastle Upon Tyne,
NE3 4BY

Not available

* Denotes a required field

If the tooth concerned is not acutely infected please do not extract it

The Implant Foundation
77 Elmfield Road
Gosforth
Newcastle Upon Tyne
NE3 4BY

Tel: +44 (0) 191 284 5666

Fax: +44 (0) 191 285 9823

Email: info@theimplantfoundation.co.uk

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Dental Referral