Patient Referral Form
PATIENT DEMOGRAPHIC DETAILS
Title
First name
Surname
Address
Postcode
Telephone
Mobile telephone
e-mail
Date of birth
Gender Male Female
Interpreter needed? No Yes / DETAILS OF REFERRING PRACTITIONER
Name
Practice address
Practice postcode
Telephone
e-mail
DETAILS OF PATIENTS GP
GP name
Practice name and address
DETAILS OF REFERRAL
Speciality referred to: Orthodontic Oral Surgery Max-fac Restorative Special care
Is the referral: Treatment Advice/ Second opinion
Is the referral: Routine Urgent - Why is this an urgent referral?
Copy of referral given to patient? No Yes
Details of the Problem Please give an outline of the patient’s condition, diagnosis and the clinical circumstances of the case /teeth involved.
Relevant medical history and drug history
Relevant dental history Please outline any previous treatment relevant to this issue, with details of the patient’s response to treatment
Radiographs: No Yes. If there are no attached radiographs explain why
Study Models: No Yes / Do you want items returned to the practice No Yes
Date: / Signature:

Restorative referrals

Is the restorative referral appropriate? – Please respond to each question
Questions answered with NO are likely to be returned as unsuitable for advanced restorative care / NO / YES
  1. Is the patient a regular dental attender?

  1. Is the patient able to maintain good oral hygiene and maintain any definitive restorations?

  1. Is the patient able to open their mouth sufficiently to provide treatment?

  1. Have alternative treatment options been discussed with the patient?

  1. Is the patient willing and able to pay NHS charges for definitive restorations?

  1. Has the patient agreed to a specialist referral?

  1. Has the initial treatment been completed? (e.g. non-surgical perio treatment, first attempt RCT)

  1. Has the patient been relieved of pain?

  1. Is the patient aware treatment is not available under General Anaesthetic or sedation?

Teeth present

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

8 / 7 / 6 / 5 / 4 / 3 / 2 / 1 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8
/ BPE DATE:

Mobile Teeth Grade:

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
/ Plaque score history
Patient must be able to maintain plaque score of 20% or less

Procedure requestedPlease clearly state the proposed specialist treatment plan for the patient.

Please outline the health outcomes anticipated if the treatment is provided

Why is a specialist required? (why can the patient’s needs not be met in general dental practice?)

Periodontal Information A full (recent) 6 point pocket chart must be included with the referral
Please provide a description of the periodontal treatment carried out with dates(treatment completed must include OHI, sub gingival debridement of all pockets>4mm and removal of overhangs)
NO / YES
Does the patient smoke?
If a smoker, has the patient been sign-posted to smoking cessation services?
(referrals without an up-to-date 6PP chart will not be accepted)
Endodontic information
Please explain why the tooth/teeth in question is/are of strategic importance.*
NO / YES
Can the tooth/teeth be adequately restored following RCT? (All caries should be removed)
Do the tooth/teeth have adequate bony support and good long-term periodontal prognosis?
Can the patient tolerate rubber dam?
Would the patient prefer an extraction?
Fixed Prosthodontics - (Teeth require adequate bony support and good long term periodontal prognosis)
Please explain why the tooth/teeth in question is/are of strategic importance*
Removable ProsthodonticsPlease detail any previous attempts to make dentures and issues that may have arisen, e.g. how many denture sets has the patient already worn? What were previous problems? Are there any predisposing factors e.g. bony protuberances, resorbed ridges?
Tooth wear - Confirm that this is stable and what symptoms the patient is presenting with – sensitivity, aesthetic, or functional problems.

* The term Strategic Importance refers to teeth that contribute to achievement of a shortened dental arch (SDA). This is normally taken to mean a functionally and aesthetically acceptable dentition, i.e. when all anterior teeth and 3-5 occlusal units are present. A pair of occluding premolars corresponds to one occlusal unit and a pair of occluding molars to two units.