Referral Form - Dentist Cambridge

For all patient referrals, please fill out the referral form below.

Referring Dentist Details
Dentist Title:
Dentist Name:*
First Last
Hidden
Old Dentist Name:
Dentist Email address:*
Dentist Telephone:*
Dentist Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date:*
DD slash MM slash YYYY
Patient Details
Title:
Name*
First Last
Hidden
Old Name
Email address:*
Date of birth:*

Day
Month
Year
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone (daytime):
Telephone (evening):
Telephone (mobile):
Reason for referral:
Relevant medical history:
Type of referral*
- Multidisciplinary
- Periodontology
- Endodontics
- Restorative/Prosthodontics
- Orthodontic
- Minor Oral Surgery
- Pain management
- Facial Aesthetics
- Other
Upload Radiographs/Pictures
Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 256 MB.

Note to our referrers

It is our policy to limit referral activity to the referral itself and refer patients back for care to their general dental practitioner. We believe that this collaborative approach to care is in the patient’s best interest and forges a healthy partnership between you the referrer and our Specialists or Complex Care Providers and our mutual patients. Our Complex Care Providers are non-specialist surgeons with proven expertise in certain areas of dentistry. We also have specialists in Prosthodontics, Endodontics, Periodontics, Orthodontics and Minor Oral Surgery. Several of our practitioners also have a special interest in pain management by the use of low level laser therapy and facial aesthetic services.

If you ever have any queries about referral care please do not hesitate to e mail our practice manager and she would be pleased to assist you. Please e mail on :

[email protected]

For all patient referrals, please fill out the referral form below.

Referring Dentist Details

Patient Details

Note to our referrers

Endodontics

Periodontics

Dental Implants

Orthodontics

TMJ & Facial Pain

Antwerp Implant Dentistry will thoroughly treat your gum disease before commencing implant therapy !

What we will do for you