Referral Form – New Park House Dental Centre

- Patient Details
- Patient Name*
  Title First Name Last Name
- Patient Address*
  Street Address Address Line 2 City Post Code
- Patient Phone Number*
- Patient Email Address*
- Date of Birth*
  
  Day
  Month
  Year
- Referring Practitioner
- Dentist's Name*
- Dentist's Phone Number
- Practice Name*
- Practice Email*
- Practice Address*
  Street Address Address Line 2 City County Post Code
- Treatments Required
- Select treatments*
  As you check each box, additional fields will open below requiring further information. Please only select one treatment option per referral.
  - Implant surgery
  - Endodontic treatment
  - Aesthetic and advanced restorative treatment
  - Orthodontics
  - Minor Oral Surgery
  - Conscious Sedation
  - Hygienist / periodontal services
  - Radiography (CBCT / OPG / Lat Ceph)
  - Facial Rejuvenation (Botox®)
  - General Dentistry / Other Referral
- Implant Surgery Details
- Choose service*
  - Implant Placement and Restoration of Implant(s)
  - Implant Placement and return for restoration(s)
- Referring Dentists Comments for Implant Surgery
- Endodontic Treatment
- Choose service*
  - Endodontic treatment and return for restoration(s)
  - Endodontic treatment and Restoration
- Does this patient require an urgent pain relief appointment for acute symptoms?
  - Yes
  - No
- Does this patient require an urgent pain relief appointment for acute symptoms?
  - Yes
  - No
- We aim to see these patients within 24 hours. Radiographs are required to help with triage.
- We aim to see these patients within 24 hours. Radiographs are required to help with triage.
  
  *Important: Please follow up with a brief phone call so we may action this urgent request as soon as possible.
- Referring Dentists Comments for Endodontic treatment
- Aesthetic and advanced restorative treatment
  
  Any photographs or radiographs are appreciated but not required. These can be added to your referral at the end of this form
- Referring Dentists Comments for Aesthetic and advanced restorative treatment
- Orthodontics
- Orthodontics Patient*
  - Adult
  - Child
- Choose Option*
  - Fixed Orthodontics
  - Invisalign / Clear Aligners
  - No preference
- Please only use this form for private orthodontic referrals.
  
  NHS referrals can be made via Rego when available.
- Referring Dentists Comments for Orthodontics
- Hygienist / periodontal services
- Following BSP classification. Please tick.*
  
  Generalised Gingivitis
  
  Localised Periodontitis
  
  Generalised Periodontitis
- Stage*
  Stage I (Early/Mild)
  Stage II (Moderate)
  Stage III (Severe)
  Stage IV (Very severe)
- Grade*
  Grade A (Slow)
  Grade B (Moderate)
  Grade C (Rapid)
- Status*
  Currently stable (BOP <10%, PPDs ≤4mm, No BOP at 4mm sites)
  Currently in remission (BOP ≥10%, PPD≤4mm, No BOP at 4mm sites)
  Currently unstable (PPD ≥5mm, or PPD ≥4mm & BOP)
- Risk Factors
- Treatment Plan
  Targeted oral hygiene instruction including plaque and bleeding indices
  Periodontal assessment – 6PPC
  Supra/sub PMPR
- POM prescription from referring dentist to hygienist for Local Anaesthesia
  If needed, please administer topical and local anaesthesia. Please use (select multiple options if appropriate):
  No local anaesthetic to be used
  Articaine 4% with 1:100,000 Adrenaline (Infiltrations only).
  Lidocaine Hydrochloride 2% with 1:80,000 Adrenaline.
  Prilocaine Hydrochloride 3% with Felypressin 0.54 micrograms/ml.
- Reason for referral*
  Please advise on the reason for referring this patient. Has any periodontal treatment been completed so far?
- Referring Dentists Comments for Hygienist / periodontal services*
- Radiography (CBCT / OPG / Lat Ceph)
- Please select*
  
  OPG / Lat Ceph
  
  CBCT
- How would you like to receive the radiograph?*
  
  Photographic Paper
  
  Emailed
- Please select area(s) for CBCT scan*
  
  Maxilla
  
  Mandible
  
  Small volume
- Tooth / Region to be scanned*
- Imaging Stent Provided*
  
  Yes
  
  No
- How would you like to receive the CBCT?*
  
  Download Link (Recommended)
  
  On CD
- How would you like to report on the CBCT?*
  
  CBCT will be reported on by referring dentist (as per CBCT SLA)
  
  Please arrange for radiologist report (£100 fee applies)
- Consent
  I understand that if I elect to report on radiographs and CBCT scans, I accept responsibility for ensuring my training is adequate.
- Referring Dentists Comments for Radiography (CBCT / OPG / Lat Ceph)*
- Facial Rejuvenation (Botox®)
- Referring Dentists Comments for Facial Rejuvenation (Botox®)*
- Conscious Sedation
- What procedure is sedation required for:*
  
  Restorative Dentistry
  
  Oral Surgery
- Conscious Sedation Notes
  
  Please note patients must be 18 years or over and we are not able to offer inhalation sedation.
  
  Please send radiographs wherever possible. These can be added to your referral at the end of this form.
- Conscious Sedation Comments by Referring Dentist
- General Dentistry / Other Referral
- Referring Dentists Comments for General Dentistry / Other Referral*
- Sedation Information
- Sedation*
  
  With sedation (patients must be 18 years or over)
  
  Without sedation
- Please send radiographs wherever possible. These can be added to your referral at the end of this form.
- Referring dentist's comments
- This field is hidden when viewing the form
  Do you have additional files to send in support of this referral?
  
  Yes
  
  No
- File Attachments (radiographs, photographs etc)
  
  Drop files here or
  
  Accepted file types: jpg, pdf, doc, docx, Max. file size: 512 MB.
- Referring Practitioner Signature
- Consent*
  I agree to the privacy policy.
  The full Dental Focus privacy policy which covers how your data is saved and stored can be found by clicking here.
  
  The practice policy for New Park House Dental which explain how the practice will store and process your data can be found by clicking here.
- Today's Date*
  DD slash MM slash YYYY
- Comments
  This field is for validation purposes and should be left unchanged.

Secure Patient Referral Form

Patient Details

Referring Practitioner

Treatments Required

Implant Surgery Details

Endodontic Treatment

Aesthetic and advanced restorative treatment

Orthodontics

Hygienist / periodontal services

Radiography (CBCT / OPG / Lat Ceph)

Facial Rejuvenation (Botox®)

Conscious Sedation

Conscious Sedation Notes

General Dentistry / Other Referral

Sedation Information

You are now in a secure area