Refer a patient Download referral form Referrer details Practitioner Name* Practitioner GDC/GMC number* Email* Phone* Practice Address* Patient details Name* DOB* Address* Mobile/Telephone* Email Teeth Requiring Treatment RIGHT UR8UR7UR6UR5UR4UR3UR2UR1 LR8LR7LR6LR5LR4LR3LR2LR1 LEFT UL1UL2UL3UL4UL5UL6UL7UL8 LL1LL2LL3LL4LL5LL6LL7LL8 REASON FOR TREATMENT Unrestorable (caries/fracture/roots)Infection/Pain - patient does not want to save (all options discussed)ApiceptomyOther (please put full details in further information box below)Confirm to NICE guidelines for third molar removal (Click here for guidance) APPOINTMENT REQUIRED Consultation onlyConsultation and Treatment Referral information Reason For Referral —Please choose an option—CBCT ScanOrthodonticsEndodonticsCosmeticOther Radiograph included - Dated Bridge/crown is cemented TemporaryPermanent Any Relevant Medical History* (including : antiplatelet/anticoagulants/bisphosphonate/steroid use; heart issues requiring ab cover; blood/bleeding disorders) Further information* (please provide any further details) Upload Radiograph(s)/additional x-rays/documents/Photo(s)/Other information* I confirm that I retain responsibility for post-operative care and for the assessment and management of complications within the normal scope of general practice, including referral back to the specialist service or onward to secondary care where clinically indicated.
