Referring Dentist Name:

Patient Name:

Referring Practice Address:

Patient Address:

Patient Date of Birth :

Patient Tel Number:

General medical practitioner details:

Date of referral:​

History presenting complaint:

Treatment referred for: (please give long hand tooth notation eg upper left second molar)

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Chart tooth for extraction - Upper Left

Chart tooth for extraction - Upper Right

Chart tooth for extraction - Lower Left

Chart tooth for extraction - Lower Right

IV Sedation with midazolam: (select yes or no)

Relevant medical history​. Please tick as appropriate 

Any other relevant medical history:​

Medications list:​

If referral is for sedation please provide Weight and Height:

Smoke: (select yes or no)

Alcohol units per week​

Mobility support required? (select yes or no)

Relevant radiographs attached?​

NB if referring a lower wisdom tooth, please provide an OPG.  If you do not have access to an OPG machine, please state below and we can arrange this at the practice for a fee.

Do you need OPG (select yes or no)