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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 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 Page 1 of 2 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 Page 2 of 2