Implant & Restorative Referrals - My New Smile

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6 Draybank Road Broadheath Altrincham WA14 5ZL

0161 348 7830

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Home
Treatments & Solutions
Common Problems & Solutions
Meet The Team
Fees
Referrals
New Patients
Contact Us

0161 348 7830

Emergency Dental Care

Home
Treatments & Solutions
Common Problems & Solutions
Meet The Team
Fees
Referrals
New Patients
Contact Us

Menu

Home
Treatments & Solutions
Common Problems & Solutions
Meet The Team
Fees
Referrals
New Patients
Contact Us

Implant & Restorative Referral

Patient Title:

Name:

Patient Address:

Date of Birth:

Contact Number:

Referring Dentist Name:

Practice Address:

Please provide a brief description about the affected teeth:

Consultation only Provide Treatment Asessment/Advice/Treatment planning only Implant surgery and associated restorative treatment Other restorative treatment Single unit Multiple units Overdentures Mixed - surgical/restorative/prosthodontics Aesthetics Routine care under sedation Occulsal Problem Toothware Other

Other Info:

Please confirm a clear radiograph is attached (essential) Further Details (if required)

Please provide 6 point periodontal probing depths around the tooth requiring treatment

Further Details (if required)

ADDRESS

6 Draybank Road Broadheath Altrincham WA14 5ZL

OPENING TIMES

Tuesday

9:00 AM – 9:00 PM

Saturday

9:00 AM – 13:00 PM

CONTACT US

01613487830
info@mynewsmilealtrincham.co.uK

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