REQUEST AN APPOINTMENT

Dr H S Elmanharawy
Registered Specialist Oral Surgeon

Qualifications

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.