Download Dental Services Referral Form

Dental Services Referral Form- Oral Maxillofacial Surgery
Date
/
/
Title:
Surname
Street address
Given name
Date of birth:
Suburb
Postcode
Name of Residential Facility (if applicable)
Room:
Phone -
Home:
Mobile:
Work:
Country of birth:
Needs interpreter:
Indigenous status:
Concession Card type:
Yes
No Language:
Neither Aboriginal nor Torres Strait Islander
Aboriginal but not Torres Strait Islander
Torres Strait Islander but not Aboriginal
Both Aboriginal and Torres Strait Islander
Pensioner Concession Card
Concession Card No:
Not Stated
Health Care Card
Expiry date:
For Under 18 patients:
Parent/Guardian name(s):
Relationship to patient:
Phone:
School:
For patients unable to provide self-consent:
Person Responsible name:
Relationship to patient:
Address:
Phone:
Ability to attend appointments at short notice if available due to vacancies:
Within 24 hours
Within 1 week
No, require more notice
Once complete please return to:
Patient Services Centre
The Royal Dental Hospital of Melbourne
GPO Box 1273L
Melbourne 3001
Revised September 2014
Oral Maxillofacial Surgery. For clinical criteria, exclusions, and patient information – Click here
Reason for referral:
Treatment urgency
Urgency 1: Suspected malignancy, trauma,
medical priority, patients to be seen the
same day
Urgency 2: Patient experiencing pain
Urgency 3: Patient not experiencing pain
Examination and treatment
Opinion only
from information provided
from examination of patient
Are you referring this patient to more than one RDHM Clinic?
No
Yes – please specify the other RDHM clinic(s)
Domiciliary Services
Oral Medicine – Mucosal
Orthodontics
Prosthodontics - Fixed
Endodontics
Oral Medicine - Facial Pain & TMD
Paediatric Dentistry
Prosthodontics – Removable
Implant
Oral & Maxillofacial Surgery
Periodontics
Special Needs
Patient’s / Person Responsible’s main concern / dental needs (in their own words):
Details for the referral:
Briefly describe how the service requested fits in your overall treatment plan.
Summary of medical history: (please attach patient’s current full history)
Notable issues
Physical or sensory
impairment
Intellectual
impairment
Falls Risk / Pressure
Ulcers
Medications
Allergies
Other significant
risks
Summary information
Details
attached
Sight
Hearing
Physical
None known
Learning
Behaviour
Communication
None known
Falls Risk
Pressure Injuries
None known
Prescribed
Self administered
None known
Yes
No
None known
Yes
No
None known
Revised September 2014
Requirements checklist
Additional information
required;
Current OPG (all cases) less than 12 months old
sent
patient to bring (only for Urgency 1 referrals - where immediate attendance has
been arranged with RDHM)
Pain relief provided
Not required
yes
Details of pain relief:
Screening clinician’s notes (RDHM use only):
Waiting list and appointment requirements
Referral not appropriate for OMFS
P1 – apt. in 1 – 2 days
Routine
Transfer to ……………………… clinic
P2 – apt. in 1 – 2 weeks
Orthognathic clinic
Incomplete referral
P3 – apt. within 4 weeks
Implant clinic
Not accepted
Date……………Code…………………Signature……………………………………
Phone:
Referring Clinician details:
Or completed on behalf of
Please record provider type
Dentist
Oral Health Therpaist
Dental Therpaist
Dental Hygienist
Other
Clinic mailing address:
Revised September 2014
Criteria – Oral Maxillofacial Surgery
Appropriate patients
Clinical criteria
- please tick options
applicable to this
patient
Patients anticipated to require specialist level diagnosis and management of Dentoalveolar conditions
Conditions that could be affecting the mouth and area around the mouth, such as:
Impacted teeth (including wisdom molars, supernumerary and other teeth)
Extraction of difficult teeth
Diagnosis and treatment planning of jaw deformities
Cysts and tumors of jaw
Other soft tissue lesions of the oral cavity
Criteria for urgency
1 referrals
Dento-alveolar surgeries for patients with complex medical histories
(e.g radiotherapy, bisphosphonates)
Conditions that may require urgent referral management include:
Suspected malignancy
please tick options
applicable to this
patient
Process for urgency
1 referrals



Consultation
A completed version of this form must be either faxed to (03) 9341 1214 or given to
the patient to bring with them. The patient must bring all radiographs. After an
appointment has been organised, the patient should be directed to proceed to the
main hospital reception.
Due to demand, it may not be possible to provide the care proposed for a particular
patient on the same day. This particularly applies to patients requiring General
Anaesthesia. However, patients with a suspected malignant lesion and patients
with potential serious infections (e.g spreading cellutitis, submandibular abscess)
will be seen on the same day.

As RDHM cannot guarentee the capacityy to see all patients, sending patients
without prior phone notification may lead to them being sent away.

Patients meeting the referral criteria will be offered an initial consultation to assess
treatment requirements.
Patients assessed as needing procedures under General Anaesthesia will be
placed on the appropriate waiting list.
Waiting times are generally shorter for procedures that can be performed under
local anaesthesia.


Ongoing care
required by
referring clinician
Dento-alveolar infections that do not have systemic signs and symptoms, have
adequate mouth opening and may not need IV antibiotics.
(Patients who have deteriorating systemic signs and limited mouth opening should
be referred directly to Medical Hospitals).
Patients suspected to have BRONJ.
Tooth or roots pushed into a sinus or other space.
The referring clinnician is to contact RDHM on (03) 9341 1277 to speak to the Oral
Maxillofacial Surgery Clinic directly, to co-ordinate care and ascertain the ability of
the clinic to provide care on the day.
By submitting this referral, I on behalf of the referring clinic, agree to:
ensure that apporpriate pain relief is provided to the patient, as required.
overall general care to this patient while on the waiting list.
Where patients are required to return to RDHM for post-operative review and fail to
do so, the referring clinician will be notified. RDHM will request that the referring
clinician encourage patients to attend their post-operative review, where possible.
Some straightforward post-operative reviews will be directed to the referring dentist
to undertake, especially in rural areas.
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Revised September 2014