Get the free Implant Referral Form

This form is used to refer patients for dental implant evaluations at WesternU Health The Dental Center. It requires patient and doctor information, relevant clinical details, and information about the specific implant needs. Referrals must be faxed to the dental center before scheduling an appointment, which requires a consultation fee.

How to fill out implant referral form

How to fill out implant referral form

1. Obtain the implant referral form from your dental office or the website of your dental specialist.
2. Fill in the patient's full name, contact information, and date of birth at the top of the form.
3. Provide details of the referring dentist, including their name, practice address, and contact information.
4. Include a brief medical history of the patient, highlighting any relevant health conditions or medications.
5. Detail the dental history, including previous treatments, any extractions, and current dental issues.
6. Specify the type of implant needed and any special requirements or considerations for the procedure.
7. Attach any necessary diagnostic documents, such as X-rays or scans, that may assist in evaluation.
8. Review the information for accuracy before submitting the form to the dental specialist.

Who needs implant referral form?

1. Patients who are candidates for dental implants.
2. Dentists who identify patients requiring implant procedures and need to refer them to a specialist.
3. Oral surgeons or periodontists seeking patient referrals for implant placement.

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What is implant referral form?

The implant referral form is a document used to request and record referrals for dental implants, often used by dental professionals to refer patients to specialists.

Who is required to file implant referral form?

Dentists and dental specialists who are referring patients for implant procedures are required to file the implant referral form.

How to fill out implant referral form?

To fill out the implant referral form, provide patient details, including name and contact information, specify the type of implant needed, and include relevant medical history and any necessary documentation.

What is the purpose of implant referral form?

The purpose of the implant referral form is to streamline the referral process, ensuring that all necessary patient information is communicated effectively between referring and receiving dental professionals.

What information must be reported on implant referral form?

The implant referral form must report the patient's personal information, dental history, type of implant requested, and any pertinent medical or treatment information.