Download Patient Details - East Cheshire NHS Trust

Community Dental Service – Paediatric Exodontia Referrals
(Treatment MUST include at least 1 extraction)
We can only accept referrals for general anaesthesia for children aged up to 16 years
Patient Details:
Surname:
First Name:
Address:
Date of Birth:
Gender:
Home Telephone No:
Postcode:
Contact name:
Relationship to patient:
Mobile:
Work:
NHS No:
GP:
GP Practice:
Behavioural Management
General Anaesthetic Ensure you have explained risk to parent
Inhalation Sedation
DENTAL PROBLEM(tick)
Pain
Trauma
Sepsis/abscess
Periodontal
Gross caries
Orthodontic Extractions
Teeth requiring extraction:
DENTAL HISTORY:(tick) No previous treatment
Restorations
Dressings
Inhalation sedation
Local anaesthesia
General anaesthesia
Radiographs include radiographs for all permanent tooth restorations or extractions
Details/Reason radiographs are not included:
Preventive care and advice already given:(tick)
Diet advice/analysis
Fluoride advice
Has the patient had Fluoride treatment in the past 3 months
Oral hygiene
Topical fluoride
Yes
No
RELEVANT MEDICAL HISTORY
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Community Dental Service – Paediatric Exodontia Referrals
(Treatment MUST include at least 1 extraction)
We can only accept referrals for general anaesthesia for children aged up to 16 years
JUSTIFICATION FOR REFERRAL:(tick)
Preschool child not mature enough
to accept LA
Insufficient cooperation to attempt
LA
Does this patient require an Interpreter?
Treatment attempted with LA but not
tolerated
Treatment required in multiple quadrants
Yes
No
If Yes please specify
ANY OTHER INFORMATION
Practice Details
Date of exam:
Dentist name
Signature
Please send to Either:
Community Dental Service (Referrals), Weston Clinic, Earlsway, Macclesfield, SK11 8SR
Or email from an NHS mail account to [email protected]
Telephone No for enquiries 01625 422501
Or
Community Dental Service (Referrals), Eaglebridge Health & Wellbeing Centre, Dunwoody Way, Crewe, CW1
3AW Or email from an NHS mail account to [email protected]
Telephone No for enquiries 01270 275792
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