Download Dentists Downloadable Referral Form

Patient details
Referrer details
Name:
Dentist name: ………………………………………………………………
DOB:
……………………………………………………………………
___/___/___
NHS / Private (Please tick)
Practice name: ………………………………………………………………
Address: ……………………………………………………………………
Practice address: ……………………………………………………………
……………………………………………………………………
..…………………………………………………………
Postcode: ……………………………
Tel: …………………………………………
CHI / HS No: ……………………………
Email address: …………………………………………
Tel home: ……………………… Tel mobile: ………………………
Relevant Medical History:
General assessment of dental health:
Details:
Oral hygiene: poor / fair / good
Teeth of poor prognosis?:
Dental History:
Attendance: regular / infrequent / new to practice
Other relevant details:
Reason for referral
Patient’s complaint:
Radiographs enclosed: yes / no / emailed
Other relevant details:
Status of referral: routine / urgent (Please tick)
Date of x-rays: ___/___/___
If urgent referral please clarify reason: (including details of overjet / canines if appropriate)
Patient / Parent / Guardian understands why this orthodontic referral has been made and gives their consent to
referral for orthodontic treatment.
(Please tick)
Referrer’s signature:
[email protected]
Date:
___/___/___
14 Finaghy Rd South, Belfast BT10 0DR