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Online Referral Form | Dentist Area

Thank you for referring your patient to us – we thrive on being able to assist patients with challenging dental problems.

Please complete the referral form below with as much detail as possible. You can also attach images. If you have any images or other type files  such as CBCT scans, please use WeTransfer to send them to info@drloukasimplants.com

We will contact your patient as soon as possible and keep you posted of progress.

Thank you!

Referring Practitioner


Patient Details


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Patient History


ExcellentAbove AverageAverageBelow AveragePoor


NormalAbnormal


MinusMildModerateSevere


MinusMildModerateSevere


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YESNO

Referral Details


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YESNO


YESNO




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