639 Lisburn Road, Belfast County
Antrim BT9 7GT, Northern Ireland
Email Us   |   How to Find Us
Call :  028 9038 1822


Cranmore Dental & Implant Clinic accepts referrals from other dentists and dental practices.
To make a referral, download and print our PDF Referral Form.

Alternatively, use the email form below.

Please be assured that we will neither approach nor accept your patient for non-referred treatment.
97 Brunswick Road Bangor County Down BT20 3DW
T : 028 9127 0634   F: 028 9127 2635
E : info@bangorwestdental.co.uk
W : www.bangorwestdental.co.uk
639 Lisburn Road Belfast County Antrim BT9 7GT
T : 028 9038 1822
E : info@cranmoredental.co.uk
W : www.cranmoredental.co.uk
   
Practice details
Referring Practice : Date :
Practice Address :    
Referring Dentist : Tel :
Email :    
       
Patient details
Patient Name : Date of Birth. :
Patient Address : Mobile :
Tel Home : Tel Work :
Email :    
Is this referral urgent? Yes    No    
       
Referral Information (Please tick all relevant boxes)
Resons for referral
Full mouth reconstruction
Implant assessment, placement & restoration
Implant placement & refer back for restoration
Opinion only
Single tooth missing
Multiple teeth missing
Totally edentulous jaw(s)
Types of implant retained restoration which have been explained to the patient
Single tooth implant
Partial overdenture
Full restorative case including
perio & implants
Implant supported bridge
Full overdenture
Is your request for implant placement only?
Yes    No
 
Has the patient been made aware of the level of investment that may be required?
Yes    No
Affected areas
Upper    Lower    Both
   
     
BRIEF HISTORY (Comments about this referral)
 
DIAGNOSTIC AIDS (Please tick all relevant boxes)
In order to minimise unnecessary exposure please indicate which radiographs you are sending with the referral
OPG    PA’s    Other Radiographs
 
Send

Clinical Director: Dr David Nelson BDS MSC (Imp Dent) 639 Lisburn Road Belfast County Antrim BT9 7GT

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