TREATMENT REFERRAL FORM

REFERRING DENTIST

PATIENT DETAILS


Referral for:

 Endodontics Urgent?  Yes No
 Implants Urgent?  Yes No
 Peri-Implantitis Urgent?  Yes No
 Sedation Urgent?  Yes No
 Periodontics Urgent?  Yes No
 Prosthodontics Urgent?  Yes No
 Restorative Dentistry Urgent?  Yes No
 Surgical Dentistry Urgent?  Yes No
 Other (Please State) Urgent?  Yes No

Referral details


HISTORY

Oral condition
 Excellent Above average Below average Poor


Periodontal state
 Excellent Above average Below average Poor


Missing teeth
 UR8 UR7 UR6 UR5 UR4 UR3 UR2 UR1
 UL1 UL2 UL3 UL4 UL5 UL6 UL7 UL8

 LR8 LR7 LR6 LR5 LR4 LR3 LR2 LR1
 LL1 LL2 LL3 LL4 LL5 LL6 LL7 LL8



Pain
 0 + ++ +++


Swelling
 0 + ++ +++

Documents

Small documents can be uploaded here. If you are intending to send us documents over 2MB in size please send them seperately via email by clicking this link.

Document 1:
Document 2:
Document 3:
Document 4:

Patient records In post?  Yes No or Uploaded/Emailed To Return?  Yes No
Consent form In post?  Yes No or Uploaded/Emailed To Return?  Yes No
Study models In post?  Yes No or Uploaded/Emailed To Return?  Yes No
Radiographs Intra-oral:
In post?  Yes No or Uploaded/Emailed To Return?  Yes No
Radiographs Panoral: In post?  Yes No or Uploaded/Emailed To Return?  Yes No
Dental history In post?  Yes No or Uploaded/Emailed To Return?  Yes No