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24 Furness Quay, Salford M50 3XZ
Reception: 0161 413 8330/ Courses: 0161 413 8335
reception@icedental.institute

Implant Referral Form

Implant Referral Form

School of Implant Dentistry

________________

 

If you would like to register for an implant treatment at the ICE School of Implant Dentistry, you will need to be referred by your General Dental Practitioner.

Please download and fill in the ICE Implant Referral Form here and return it to reception@icedental.institute. Alternatively, you can fill it out below.

Once you have been referred to ICE, you will have a free initial consultation with one of our directors. Following this, you will start your treatment and the price will be subsidised on a training basis.

For further information, on the implant treatment under the ICE School of Implant Dentistry, see our Patient Information Leaflet.

Please note that any cases that are not suitable for our students will be treated by the directors.

Referral Form

Date Of Birth

Telephone Number:

Mobile Number:

Email Address:

Address:

Referring Practitioner Section Only
Name:
Practice Address:
Practice Telephone Number
Practice Email:

Proposed Treatment Details

Teeth that require treatment

Please provide further details: (e.g.
when tooth was XLA, Root Fracture
etc) ………

The patient is aware that the treatment will
be carried out by supervised clinicians
training in Implant Dentistry:

Date:
Sent In By:

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