Implant Referral

Dentists please complete the form below if you wish to refer patients to A&L Clinics for implant placement(s).

We will reply to your request as soon as we can.

Your Practice Details

Patient Details

Treatment Required

(Please indicate in which area(s) treatment is required, for fees refer to website)
Radiographs Included
Attach Radiograph (file types accepted gif/png/jpeg) File name to include referring dentist name, patient initials and patient DOB.
Will the patient benefit from sedation
Is your patient a regular attender to the hygienist?
Frequency of hygiene attendance

Referring Dentist Details

This will act as the practitioner’s electronic signature: I hereby authorize A and L Clinics to carry out an implant consultation as outlined above. (for any relevant fees please visit aandlclinics.com)
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