Author: Fadi

Refer a patient

Dental Implants
Endodontics
IV Sedation
Oral Surgery
Paediatric Dentistry
Periodontics
Prosthodontics

Menu

Dental Implants
Endodontics
IV Sedation
Oral Surgery
Paediatric Dentistry
Periodontics
Prosthodontics

Privacy Police
Terms

Patient Referral Form

DIGITAL REFERRAL FORM 2021

Patient Details
Please provide the details of the patient you wish to refer
Name*
Prefix First Last
Address*
Street Address Address Line 2 City Postal Code
Date of Birth*
DD slash MM slash YYYY
Mobile Phone Number*
Landline Phone Number
Email*

Dentist Details
Please provide the details of the referring dentist.
Name*
Prefix First Last
Practice Name*
Address*
Street Address Address Line 2 City Postal Code
Home Phone Number*
Mobile Number
Referrer Email*

Referral Details
Please provide details of the referral you wish to make.
Please indicate the discipline the referral relates to:*
- Endodontics
- Periodontics
- Prosthodontics
- Restorative Dentistry
- Implants
- Oral Surgery
- Paediatric Dentistry
- Aesthetic Dentistry
- Orthodontics
- Inhalation Sedation
- IV Sedation
- Imaging / Radiograph
Preferred Clinician for Endodontics*
Would you like us to carry out the definitive restoration (e.g. crown or onlay) at our practice?*
- Yes
- No
Would you like us to place a direct core (& post if appropriate) prior to returning the patient back to your practice?*
- I intend to place the core myself and would prefer you to place a temporary restoration
- Please place a direct core
- Please place post and core if required
Referred to Periodontics*
Referred to Prosthodontics*
Referred to Restorative Dentistry*
Referred to Implants*
Referred to Oral Surgery*
Referred to Aesthetic Dentistry*
Referred to Paediatric Dentistry*
Referred to Orthodontics Dentistry*
Referred to Inhalation Sedation*
Referred to IV Sedation*
Who would you prefer to provide restoration of the implant(s)?*
If your preferred service provider has a longer waiting time, are you happy for this referral to be booked with another clinician?*
- Yes, this is ok
- No, I prefer my referral to remain with my preferred clinician
If the patient requests treatment on adjacent teeth at the same time as having implant treatment are you happy for this to be offered as part of the same treatment plan at our practice.*
- Yes, this is ok
- No, please refer them back to me for further discussion
If it is deemed that the patient requires/would benefit from hygiene support prior to undertaking implant treatment, we will arrange for this to be done within our team at our Referral Centre. If you would prefer us to refer back to you for hygiene support prior to implant surgery, please let us know below*
- I am happy for my patient to have pre-operative hygiene support at our referral Centre
- I would prefer for you to send the patient back to our practice for stabilisation
Following restoration of the implant, the patient will be discharged back to you for all ongoing care and maintenance. However, if you would like us to assist in providing ongoing implant maintenance support to the patient with our hygienist team into the future, we would be more than happy to. Is this something you would like us to offer to your patient on completion of treatment?*
- Yes please
- No thank you, we will provide hygiene support within our own practice
Teeth chart
Please indicate which teeth the referral concerns.
Please indicate which teeth the referral concerns.*
If tooth requires endodontic treatment and is not restorable*
If the tooth that requires endodontic treatment and is not restorable, would you be happy for us to offer extraction and / or treatment to replace the tooth?
- I am happy for you to offer further treatment
- I would prefer to discuss and plan the next stage with the patient myself
Radiograph
Type of radiograph requested*
- 2D
- 3D
- Ceph
2D Radiograph Options*
- Standard
- OPT
- TMJ
- L
- R
- OPT Bite Wing
Single*
- L
- R
- Type of radiograph requested
3D Radiograph Options*
- Full Dentition
- Single Arch Maxilla
- Single Arch Mandible
- Sinus
- Small FOV
- OPT Bite Wing
- Standard Definition
- High Definition
Please specifiy area (Small FOV)*
Ceph Radiograph Options*
- Lateral
- Antero-Posterior
Clinical context for requesting the above examination
Relevant results of history, clinical examination, and other imaging
What information do you want the radiographic examination to provide?
Define the anatomical area that the radiograph should cover
Radiograph / Imaging Consent*
*If, under the service level agreement images will be reported on by the referring practice unless otherwise specified above
The referring practice will then be responsible for ensuring the clinical evaluation takes place and is properly recorded.
I agree.

Relevant medical history (incl. smoking status)*
Referral information
Please upload any relevant files
Drop files here or

Max. file size: 180 MB, Max. files: 6.

Enclosures
Please let us know if you have provided any additional information with this referral. We would be grateful if you would provide any relevant radiographs alongside your referral.
To reduce paper and improve efficiency, we would like to contact you by email with updates on your patient's treatment, please indicate if you would prefer an alternative means of contact
- Happy to receive correspondence by email
- I would prefer to receive correspondence by post
- Other
Other (please specify)
Include in mailing list to keep you informed of any additional developments or CPD events run by our practice?
- Yes
Untitled

Patient Referral Form

DIGITAL REFERRAL FORM 2021

Patient Details

Dentist Details

Referral Details

Teeth chart

Radiograph

Enclosures