Third Molar Removal

Third Molar Removal

Referral Form

Referral To:

Gloucestershire Royal Hospital r / Cheltenham General Hospital r / Date of Referral:
Patients referred for consideration for the surgical removal of third molars must satisfy one or more of the National Institute of Clinical Excellence (NICE) indications for treatment (see overleaf)

Patient Details:

Name: / DoB: / Male r Female r
Address:
Postcode:
Home Tel: / Work Tel: / Mobile Tel:
NHS referral r / Private referral r
All medical conditions, allergies/reactions and medications:

Radiographs

Following discussions with the PCT Dental Advisor we have been advised that we must request that all relevant radiographs are included with the referral letter to allow adequate assessment of the referral. If the radiographs are of insufficient quality, or not enclosed, we will regretfully return the referral to you until such time as we are in receipt of a suitable radiograph. Should the referring dentist not have suitable radiography equipment, a referral can be made to the hospital radiology department who will take an OPG that the dept of OMFS can access, to allow assessment of referral and further treatment. Hospital X-ray request forms can be downloaded from the OMF departmental website.

Radiographs included? YES r NO r N/A r
If YES, please state type:

TO BE FILED IN THE PATIENT HEALTH RECORD GHNHSFT/Y0776/04_13

The General Dental Practitioner is requested to indicate the appropriate criteria for each third molar requiring removal as indicated

Reason for Referral

UR8 / UL8 / LR8 / LL8
1. / Dates of 2 or more episodes of Pericoronitis / [ ]
Date:
Date:
Date: / [ ]
Date:
Date:
Date: / [ ]
Date:
Date:
Date: / [ ]
Date:
Date:
Date:
2. / Unrestorable caries in 8 / [ ] / [ ] / [ ] / [ ]
3. / Distal caries in 7 / [ ] / [ ] / [ ] / [ ]
4. / Non-restorable pulpal and / or periapical pathology in 8 / [ ] / [ ] / [ ] / [ ]
5. / Cellulitis, abscess or osteomyelitis / [ ] / [ ] / [ ] / [ ]
6. / Periodontal disease 7 / 8 / [ ] / [ ] / [ ] / [ ]
7. / Internal / external resorption of tooth or adjacent teeth / [ ] / [ ] / [ ] / [ ]
8. / Fracture of 8 / [ ] / [ ] / [ ] / [ ]
9. / Disease of follicle including cyst / tumour of 8 / [ ] / [ ] / [ ] / [ ]
10. / Orthodontic indications
(Please include orthodontist’s request)
NB. Crowding of incisors is not an indication for removal of 8s / [ ] / [ ] / [ ] / [ ]
Duration of symptoms: / Less than 3 months / [ ] / [ ] / [ ] / [ ]
4 – 6 months / [ ] / [ ] / [ ] / [ ]
7 – 12 months / [ ] / [ ] / [ ] / [ ]
13 – 24 months / [ ] / [ ] / [ ] / [ ]
25+ months / [ ] / [ ] / [ ] / [ ]
Signature of referring dentist: / Date:
Name of referring dentist (please print):
Address of referring dentist:

NB. Please ensure form is fully completed before submitting referral to OMFS Booking Office, GRH.

Incomplete forms will be returned to sender without an appointment being made.

As at April 2017

TO BE FILED IN THE PATIENT HEALTH RECORD GHNHSFT/Y0776/04_13