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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