Practice Details

Referring Practice

Practice Address

Referring Dentist




Patient Details

Patient Name

Patient Address

Is this referral urgent?

Tel Home


Date of Birth


Tel Work

Reasons for Referral

Implant assessment, placement and restoration.Implant placement and refer back for restoration.Opinion only.

Affected Areas

Brief Dental and Medical History

Diagnostic Aids (Please tick all relevant boxes)

In order to minimise unnecessary exposure please indicate which radiographs you are sending with the referral:

OPGPAsOther Radiographs


Dear Patients,

The recent pandemic has disrupted all of our daily lives. The situation is ongoing and currently subject to daily changes. The team at St Johns remain dedicated to providing appropriate dental care during the crisis.

The premises is currently closed however we have diverted the main telephone number to 07511 288372 during the shutdown. Please contact us if you require advice on clinical issues. To cancel or rebook appointments please use the email and we will contact you when we reopen to rebook the appointment.

Our team is missing the daily contact with you all and doing the job that we love. We look forward to reopening to provide the best dental care in safe environment.

We will update you as things become clearer. Please stay safe and well,

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