Referrals

Make a Referral

If you are a dentist looking to make a referral, Greasby Dental is happy to help. Simply fill in the form below.

Referring Dentist:

Preferred Contact Method

Written

Patient Details:

Reason for referral

Single Implant Anterior

Multiple Missing Teeth

Single Implant Posterior

Full Arch Implants

Other

Please Specify

Reason for tooth replacement

Failing crown / bridgework

Root fracture

Periodontal disease

Long standing gap

Failing endodontics

Caries

Loose Denture

Other

Please Specify

Teeth for replacement

Please make a selection from the diagram below...

Brief history of issue

Please give any other information, such as how long the tooth has been missing or if tooth is symptomatic.

Relevant Medical History

Any special dental or medical factors, such as known allergies or unusual medical treatments, should be noted.

Medications

Please upload any relevant radiographs or pictures

How would you like us to proceed with treatment?

Place implant and definitive restoration

Place implant and return to my practice for me to restore

When doing a comprehensive implant assessment, we often discuss other more comprehensive treatments with the patient to address issues such as toothwear or aesthetics. How would you like us to approach this?

Please discuss and carry out all treatment patient requires/requests.

Please contact me first after the consultation to discuss who carries out any restorative work.

I have already discussed and planned the restorative work - please place the implant only.

Other

If this is the case please provide wax up of planned treatment to allow correct 3D positioning of the implants.

Please Specify

This field should be left blank

Contact Us

0151 678 0199

230 Greasby Road, Greasby
Wirral, CH49 2PW

Send us an Email

Opening Hours

Monday to Friday
9.00am – 5.30pm
We briefly close for lunch 1pm – 2pm

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