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Online referral form

 

Preferred practice:

Referral for:

   
Urgent
Non-Urgent
Not required
Preferred Practitioner
(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 :
Phone :
Fax :
Mobile :
Email :
Practice :
Address :
Postcode :


Patient details:

Title :
D.O.B. :
Home Phone :
Work Phone :
Mobile :
Email :
First name :
Last name :
Address :
Postcode :


Referral details:

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

  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 ( Thursday, 23 October 2008 )
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