Dr H S Elmanharawy
Registered Specialist Oral Surgeon


Online Referral Form

Please complete all required fields marked*

Referring Dentist Contact Details

Patient Contact Details

Referral Urgency

Please indicate if this referral is urgent

Referral Information

Please tick all relevant boxes.

Reason for referral

Types of implant restrained restoration that have been explained to the patient

Is your request for implant placement only?
Has the patient been made aware of the level of investment that may be required?
Affected Areas
Additional Information

Diagnostic Aids

In order to minimise exposure please indicate which radiographs you are sending with the referral (Please tick all relevant boxes)

Please attach files as JPEGs (file size no greater than 4MB) or post traditional films

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Postal Referral

Alternatively if you prefer to post your referral please download, print and complete the following referral form (PDF document - Opens in a new window)

Referral Form

then post to

Cottage Dental & Implant Clinic, 8 High Street, Wootton Bassett, Swindon, SN4 7AA.