Dental Referral
Who's Who at the Parade Dental Surgery & Implant Clinic link The Parade Specialist Dental Centre - Part of the Jame Hull group
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Preferred Practitioner:

Referral for:
 
Urgent
Non-Urgent
Not required
Preferred Specialist
(if known)
Implantology
Aesthetics
Endodontics
Periodontics
Oral medicine
Pathology/biopsy
Oral surgery
Special needs
Prosthodontics
Orthodontics
Paediatric dentistry

Urgent - to be seen immediately.
Non-urgent - to be seen within 3 weeks.

Referring practitioner:
Name:
Practice:
Phone:
Fax:
Mobile:
Email:
Address:
Postcode:

Patient details:
First name :
Title:
D.O.B.:
Home Phone:
Work Phone:
Mobile:
Email:
Last name :
Address:
Postcode:

Referral details:

Purpose of referral:


Patient's main complaint:

History:
Please indicate which of the following documents are available
Patient records
   
Consent form
   
Medical history
   
Study models
   
Radiographs:
      
   Intra-oral
    
   Panoral
    
Dental history
   


Oral condition:
Excellent   Above average   Below average   Poor


Periodontal state :
Excellent   Above average   Below average   Poor

Teeth requiring attention:

Upper:
 
 
8
7
6
5
4
3
2
1
  
1
2
3
4
5
6
7
8
 
 
8
7
6
5
4
3
2
1
  
1
2
3
4
5
6
7
8
Lower:
 
                   
Pain:
 
Swelling:
 
0
+
++
+++
    
0
+
++
+++
                     
Vital:
Yes
No
  
PA Lesion:
Yes
No
 
Other Relevant Information



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Dentists area link
Links page link
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