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Referral form

Please give as much detail to support your referral as possible.

Community dental

Is this an urgent oncology referral? * required


Part 1 - About you (the referrer)
Are you a: * required





* required
* required

* required

* required
Part 2 - About the patient (being referred)
* required
* required
Gender: * required


* required
   
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* required



(if known)


(if different from part 1)

Is the patient over 21 stone in weight?



Does the patient require an interpreter? * required



Does the patient have any special needs?:
(please tick all that apply and give details below)









Is your patient in foster care/needing LAC assessment?: * required
(please give details below)



Are you aware of any safeguarding issues surrounding the patients care?: * required
(please give details below)


Are you aware of any risks associated with providing care for the patient?: * required
(please give details below)



Part 3 - For dental professionals

(please give as much detail as possible including results of radiographs etc. We will contact you for these if necessary)


Please note we do not provide IV sedation. Adults with dental phobia but no additional medical conditions should be referred to alternative sedation services.


If extractions are requested, please include a current radiograph. Referrals for extraction will be returned without a current intra/extra oral radiograph






* required
Is the patient exempt from payment?:


* required
Part 4 - For all referrers
Why can't this patient's treatment be provided in a general dental practice?: * required
(please check all that apply and give details below)








In your opinion:
Is the treatment urgent? * required


Does the patient require treatment to be provided under sedation? * required


Does the patient require treatment to be provided under general anaesthetic? * required


Is the patient suffering significant discomfort/pain/swelling? (that you have not been able to resolve with temporary treatment or antibiotics)




(please attach any additional information here i.e. digital x-rays etc) (file types accepted - doc,docx,pdf,ppt,pptx,rtf,txt,xls,xlsx,jpg,jpeg,bmp,gif,png)





You will see a thank you page once the form has been submitted. If you do not see this page then you have overlooked to complete some of the required fields. Please check the form, complete the missing details and resubmit. Thank you.

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