Online Referral Form Security Notice All data is transmitted encrypted via a secure SSL connection. Please fill in all fields with marked with a *. Patient data Patient's first name Patient's last name Date of Birth Street address ZIP City Contact phone number (private) Contact phone number (work) Contact phone number (mobile) E-mail Desired measures Medical council Physical therapy only (please add specific prescription) Radiography Orthopantomography Lateral Cephalogram Further X-Ray examination of the head (please specify) Cone Beam CT Scan (CBST) Virtual planning Implant planning (NobelClinician®) Guided surgery for other implant systems (please specify) Further virtual planning requests Treatment by specific physician M. Baltensperger MD, DMD / R. Lebeda MD, DMD / U. Teutsch MD, DMD Not for emergency procedures. If no specific physician is determined, assignment will be done according to availability. Reason of referral, further radiology specifications, specific issues that should be addressed Remarks Upload file / pictures Select your file (max 10.0 MB) Select your file (max 10.0 MB) Select your file (max 10.0 MB) Appointment Patient will call to schedule appointment Patient needs to be called up to schedule appointment Appointment has already been scheduled Date Time Treatment priority Emergency Urgent Normal Referring physician (office) / clinic Name Address Phone E-mail Remarks Send form Print
