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Restorative Dentistry Referral Pro-forma All referrals are reviewed by Restorative Dentistry Consultants. Restorative Dentistry referral criteria can be viewed on http://www.belfasttrust.hscni.net/services/DentalServices.htm. Please complete pages 1 & 2. Inappropriate referrals will be returned with specific reason(s) outlined. PATIENT DETAILS Patient Name: ____________________________________ Gender: ___________________ Address: _______________________________________ Date of Birth: _______________ ________________________________________________ Home Tel No:______________ Post Code: _______________________________________ Mobile No:________________ H&C No. _________________________________________ Interpreter Required Yes THE RELEVANT No PLEASE SELECT RESTORATIVE SPECIALITY Conservation Please do not use this form for Endodontics Periodontal Referrals Prosthodontics Language__________ IS AN INTERPRETER REQUIRED? Yes / No (please circle) If yes, which language___________ REFERRER DETAILS Name of referring practitioner: _____________________________________________________ Address: _______________________________________ Date of referral: ______________ ________________________________________________ Telephone No:______________ Post Code: ______________________ email address:___________________________________ For SoD use only: Date referral received by New Patient Appointments Office Referral Source: □ Dental Specialist □ Medical Specialist □ GDP □ CDS Referral Not Accepted □ Response letter completed □ MEDICAL PRACTITIONER DETAILS General Medical Practitioner: _____________________________________________________ Address: _____________________________________________________________________ _____________________________________________________________________________ Post Code:___________________ Contact Tel No:_____________________________ 1 Restorative Dentistry Referral Pro-forma Patient Name: DoB Referrer____________________________ CLINICAL REASONS FOR REFERRAL (if applicable provide a provisional diagnosis). BPE: Details of enclosed radiographs: _________________________________ _________________________________ _________________________________ _________________________________ Please outline treatment(s) undertaken to date to manage this patient’s dental problem (a detailed outline is expected when referrals are for specialist input on tooth ware) ___________________________________________________________________________ ___________________________________________________________________________ RELEVANT MEDICAL HISTORY AND CURRENT MEDICATIONS: Justification for Specialist Referral:_______________________________________________ ___________________________________________________________________________ Is the patient a smoker or has the patient smoked in the past 6/12? Y N No relevant medical history Previous medications of significance:_____________________________________________ __________________________________________________________________________ Wheel-chair user Ambulance required Type _____________ I confirm that this patient’s referral meets the Restorative Dentistry referral criteria issued by the Belfast HSC Trust. Signature of referring practitioner:___________________ Print name:___________________ GDP CDS Dental Specialist Medical specialist 2
