Patient Implant Referral Form

🤝 Partnering for Excellence: Dental Referrals

Erskine Dental Care is a trusted partner for dental colleagues, accepting referrals for both dental implant placement and treatment and complex surgical extractions.

Our Implant Service Options:

Surgical Phase Only: We can expertly place the dental implants, returning the patient to you for the final restoration.
Complete Care: Alternatively, we can manage the entire implant process, from surgical placement to final restoration.
Mentorship Opportunity: Dr. Philip Byrne is committed to furthering dental skills and offers mentoring and support to referring dentists interested in restoring their own implant cases.

Referring Dentist Details

Dentists Name

First

Last

Dentists Email Address

Phone

Practice Address

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Patients Details

Patients Name

First

Last

Patients Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Patients Phone Number

Patients D.O.B

Referral Details

Relevant medical details (non-mandatory)

Further case details (non-mandatory)

Patients Practice Email

Attach Radiographs

Drag & Drop Files, Choose Files to Upload

You can upload up to 5 files.

Please attach any radiograph files

Referring Dentist Details

Practice Address

Patients Details

Referral Details

Affordable 0% finance options available.

for treatments costing over £1500. Spread the cost of your treatment over 12 months, interest free.