Download Oral Surgery Referral Form

Top copy to be sent with the referral pack
Second copy to be retained by the practice
Third copy to be sent to NHS SE London
Minor Oral Surgery Referral Form for NHS Greenwich
 Please complete all pages and every section of this form and retain the second copy
for your records. Any incomplete referrals will be returned.
 All referrals must be accompanied with the relevant x-ray.
 Attached x-rays should be sealed in an envelope (marked with name) and stapled to this form.
 Referrals that do not comply with NHS Greenwich criteria will be returned to the referrer.
 Full patient contact details must be included.
PROVIDER LIST
Green Lane Dental Practice, Dr Kardel-Tabar, 377 Green Lane, New Eltham SE9 3TE
Heronsgate Dental Practice, Dr L McArdle,1 Goosander Way, Thamesmead SE28 0ER
Plumstead Dental Practice, Dr Ziaie-Tabari, 12-14 Herbert Road, Plumstead. SE18 3SH
Slade Dental Practice., Dr SH Patel, 1 Garland Road, Plumstead Common, SE18 2RU
S3 Dental, Dr Butt 72 Well Hall Road, Eltham, SE9 6SL
Referral to be sent to:
Enter the name of the specialist provider
PLUMSTEAD DENTAL SURGERY
Please place a cross in one or other of these boxes
If the referral is urgent please explain why below:
Urgent
Routine
Important. This service is restricted to patients who are resident in Greenwich. If your patient is resident in Lambeth,
Southwark, Lewisham, Bexley or Bromley please contact: the dental team at the NHS SE London at 1 Lower Marsh, for
details of MOS Providers in those areas. A list of Greenwich postcodes is included in your MOS Information Pack
Practice details
Provider contract number:
Practice address:
Name of dentist:
Postcode:
Telephone:
Fax:
Email:
Patient details
Name:
Patient’s address:
Date of birth:
Telephone:
Postcode:
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Patient’s General Medical Practitioner
Name of GP:
GP Address:
Telephone:
Postcode:
Referral reason
□Third Molars
□Routine Extraction
□Surgical Extraction
□Apicectomy
□Exposure of unerrupted □Other
□Retained Roots
□
Teeth for orthodontic
purposes
Medical history
ASA grade 1
□ 1 □ 2 □ 3/4
Main problem
□ Cardiovascular
□Respiratory
□Renal
□Liver
□ Immune suppression
□Radio-therapy
□IV Bisphonsphonates
□Psychiatric
□Sedation
□GA
Anaesthesia requested
□LA
Indication for Sedation/GA
□Phobic
□Failed LA
□ Anxious
□Disability
□Complexity of procedure □Medical Hx
Relevant notes
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This section must be completed or the referral will be returned to you
□Yes □No
□Yes □No
□Yes □No
□Yes □No
□Yes □No
Have you completed all relevant parts of the referral form?
Have you included an x ray of the whole area in question?
If for orthodontic extraction has the patient had an orthodontic consultation?
(Please include the relevant orthodontist letter)
Do wisdom teeth referrals concur with NICE guidelines?
Have you included the patient contact details?
NB: Please send a copy of the form only to: Lucky Hossain Dental Contracts & Performance Manager, NHS SEL Cluster
Primary Care, 1 Lower Marsh, Waterloo, London SE1 7NT, E-mail [email protected] or Fax: 020 3049 3358.
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