Download general anaesthetic referral to salaried dental service

Suffolk Community Healthcare
GENERAL ANAESTHETIC REFERRAL TO SALARIED DENTAL
SERVICE
To:
(Clinic Stamp)
From:
Name of dentist
Referring patient*
Practice address*
Telephone No.*
*Mandatory fields
Date…………………………………..
Please would you arrange for the following patient to be seen at your clinic for an assessment for
dental treatment under general anaesthesia.
Patient’s Name:………………………………………………………
Date of birth:…………………………………………………………
Address:…… ………………………………………………………………………
………………………………………………………………………………………
Post Code:
………………Contact Telephone No:………………
NHS No: ………………………………………………..
Please carry out the following treatment under general anaesthesia:
I enclose:
Yes No
Up to date radiographs (essential for permanent teeth)
Completed medical history form (please staple to referral form)
Orthodontic treatment plan (if applicable)
Treatment involving the extraction of just one primary tooth will only be accepted
in special circumstances
PLEASE TURN OVER
In addition the November 1998 revision of the GA Guidance by the GDC
requires the completion of all the following sections:
This patient requires a general anaesthetic for their dental
treatment because:
Yes
N/A
I confirm that other forms of treatment have been discussed with
the patient/parent
Yes
No
I confirm that the risks of GA have been discussed with the
patient/parent
Yes
No
I confirm that the patient/parent agrees to referral for treatment
under GA
Yes
No
A copy of the complete referral package should be kept in your practice
Parent/Carer’s/Patient’s Name (please print)……………………………………………
Signature…………………………………………………………………
Referring Dentist’s name (please print)……………………………………………….
Signature…………………………………………………………………
Date………………………………………………
Failure to fully complete this form may result in the form being returned to your practice and
therefore a delay in your patient’s treatment.
Amy Schiller, reviewed January 2012