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Online referral form


   
 

Preferred Practice:

Referral for:


Urgent
Non-Urgent
Not required
Preferred Specialist
(if known)
Implantology
Same day teeth
Aesthetics
Endodontics
Periodontics
Oral medicine
Pathology/biopsy
Oral surgery
Special needs
Prosthodontics
Orthodontics
Paediatric dentistry

Urgent - to be seen immediately.
Non-urgent - to be seen within 3 weeks.

Referring practitioner:

 
  Name:   Practice:  
  Address:

Postcode:
 
  Phone:  
  Fax:  
  Mobile:   Email:  

 
 

Patient details:

 
  First name :   Title:  
  Last name :   D.O.B.:  
  Address:

Postcode:
 
  Home Phone:  
  Work Phone:  
  Mobile:   Email:  

 

Referral details:

  

Purpose of referral:

Patient's main complaint:

 
 

History:

  
  Please indicate which of the following documents are available:  
 
Patient records
Consent form
Medical history
Study models
Radiographs:
   Intra-oral
   Panoral
Dental history

 
 

Oral condition:
Excellent   Above average   Below average   Poor

Periodontal state :
Excellent   Above average   Below average   Poor


Teeth requiring attention:
Upper:

 
8
7
6
5
4
3
2
1
  
1
2
3
4
5
6
7
8
 
8
7
6
5
4
3
2
1

1
2
3
4
5
6
7
8
Lower:


             




Pain:
  Swelling:
 
0
+
++
+++
    
0
+
++
+++
Vital: Yes   No   PA Lesion: Yes   No
 

 
 

Other Relevant Information

 

 
 
 
  
Last Updated ( Monday, 09 July 2007 )