Implant Referral Form

Implant Referral Form

1301 Trumansburg Road, Suite #G Ithaca, NY 14850
(607) 273-0327 Phone
(607) 273-0328 Fax

For restorative dentists:

Please use this form for referral of dental implant patients when possible. Have the patient bring it with on the consultation or, email it to us if possible. If you need prosthetic components for implants we place, the implant rep or our office will be happy to assist you in any way with the restorative phase of treatment. We will make things very easy.

Diagnostic waxups are helpful after initial consultation in ensuring proper occlusion and freeway space for more complex tooth replacement cases. We may use other implant systems depending on the best and most economical solution for patients, but we generally place Zimmer and 3i. We often use surgical guides that are Cone Beam based; for very simple cases, they may not be needed or can just furnish a hole in a suck down guide where the ideal center of the implant will go. Some cases require more detailed planning. Call me with any questions and please don’t make surgical stents without telling me as it may be a charge for something the patient doesn’t need if we are doing CT guided surgery.

Call me for any questions.

Type of Clinical Situation
Please email X-rays to