Oral Surgery Referral Form

NB This form should not be used for fast-track referrals. This includes cancer, suspicious lesions and urgent referral for serious acute conditions. These must be referred straight to the secondary care provider.

Please ensure that this form is completed properly and that all relevant radiographs are attached.

The completed form should be sent to Max Fax LLP, Holly House Hospital, High Road, Buckhurst Hill, IG9 5HX or by email from an nhs.net address only to
For any queries, contact Jackie Row Tel: 07771 967152
Date of referral
Patient Details / Referring Dental Practitioner
First Name(s) / Name of Dentist
Surname / Name of Practice
Gender / M / F
D.O.B / Address
Address
Practice Code
Postcode
Postcode / Tel.
Tel. / GP Practice
Mobile
NHS No. / Address Including Postcode
Smoker / Yes / No
Medical History / Yes / No / Relevant Details
Heart Problems
High Blood Pressure
Asthma or Bronchitis
Diabetes
Epilepsy
Medicines
Operations
Allergies
Other Relevant Ailments (Please describe)
Tooth (teeth) requiring treatment / 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
Relevant Clinical Information
Please confirm that treatment has been discussed with the patient
Radiographs enclosed
(if no radiograph available please indicate reason)
PA / OPG / Other / Date
If no radiograph is available please indicate reason
Patient referred for the following treatment:
please tick
Surgical extraction of teeth
Surgical removal of impacted teeth
Surgical removal of wisdom teeth, including impacted wisdom teeth. (NB table below must be completed)
Surgical exposure of tooth
Surgical removal of retained root of tooth
Extraction of teeth following previous failed extraction
Multiple extractions with moderate to severe complexity e.g. bulbous and sclerosed /ankylosed teeth
Simple Apicectomy;where other forms of treatment have already been attempted including root canal treatment or re-root canal treatment in line with good current practice.
Soft tissue surgery:
  • Removal of simple fibro-epithelial polyps.
  • Removal of simple mucocoele.
  • Removal of uncomplicated denture induced mucosal hyperplasia.

Surgical removal of wisdom teeth should be limited to patients with evidence of pathology according to NICE guidance. Please indicate reason for referral for removal of wisdom teeth:Please tick
Caries in distal 2nd molar or lower 3rdmolar not amenable to restorative measures
Associated follicular cystic changes
Lower third molar contributing to caries or periodontal disease of second lower molar
External or internal resorption of third molar
recurrent episodes of pericoronitis
Single episode of pericoronitis which showed evidence of spread of infection into facial tissues
Recurrent painful episode(s)
Infection

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