Please see reverse of form for guidance notes and where to send your referral.

Please note that the latest information, guidance and electronic forms are always available at

www.dental-referrals.org. Please do not use this form for maxillofacial referrals..

ORAL SURGERY FORM * ROUTINE EXTRACTIONS ONLY ACCEPTED WHEN DETAILED JUSTIFICATION IS PROVIDED FOR WHY THIS CANNOT BE DONE IN PRIMARY CARE

**PLEASE NOTE THAT THIS FORM SHOULD NOT BE USED FOR SUSPECTED CANCER REFERRALS. NOTE THAT INDICATING SEDATION / GA DOES NOT GUARANTEE PROVISION

GENERAL ANAESTHETICS ARE NOT AVAILABLE FOR HEALTHY ADULTS UNDERGOING ROUTINE PROCEDURES.

*Age of Patient in years (12years and older only):

*Patient’s Title & Name: *Sex *Date of Birth (DD/MM/YY

/ / *Patient’s Address:

*Patient’s Town or City: *Preferred Contact No: *Patient’s Postcode

Is Patient exempt YES / NO If no, has the patient paid : Band 1 Band 2 Band 3

*Referrer’s Name: *Practice Postcode: *Date of Decision to refer

/ / *Interpreter required? *Language?

YES / NO

*Practice Name and Address: *Patient’s GP Name and Address including Postcode:

*GDC Number: *Practice Phone Number: URN: ESX RADIOGRAPHS MUST BE ATTACHED FOR ALL EXTRACTIONS – PLEASE SUPPLY PA’S OF THIRD MOLARS IF NO ACCESS TO DPT

*Patient’s principle complaint: *Please indicate requested anaesthesia (please complete IOSN form if anything other than local)

Local anaesthetic only IV Sedation GA

** (eg benign oral mucosal lesions such as mucocoele/fibroepithelial polyp or facial pain/TMJ) If ‘other’ describe here or use to provide more information on your referral.

*Main Reason for referral:

ROUTINE EXTRACTION OF TEETH* DIFFICULT EXTRACTION

REMOVAL OF SIMPLE IMPACTED TEETH COMPLEX IMPACTION

SURGICAL ENDODONTICS ON SINGLE ROOTED ANTERIOR TEETH

REMOVAL OF BURIED / FRACTURED ROOT FRAGMENTS OTHER**

*For extractions, please indicate below the teeth / roots to be removed

PERMANENT DENTITION 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

PRIMARY DENTITION E D C B A A B C D E

E D C B A A B C D E

*Please describe why specialist care is required? Please describe anyprevious treatment for the condition referred. For third molars please explain how NICE guidelines are met?

*Please indicate patient’s choice of secondary care unit:

COLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST MID ESSEX HOSPITAL SERVICES NHS FOUNDATION TRUST (BROOMFIELD HOSPITAL) SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST PRINCESS ALEXANDRA HOSPITAL HARLOW CAMBRIDGE UNIVERSITY HOSPITAL NHS FOUNDATION TRUST (ADDENBROOKES HOSPITAL) BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST IPSWICH HOSPITAL NHS TRUST

*I have read and understood the guidance notes for referrals of this type (see details on reverse or at www.dental-referrals.org)

SIGNED:

PLEASE COMPLETE A MEDICAL HISTORY FORM – COPY URN TO THIS FORM – ENSURE ALL BOXES ABOVE ARE COMPLETED ADDITIONAL INFORMATION / LETTERS ETC MAY ACCOMPANY THE REFERRAL BUT MUST REFERENCE THE URN

PATIENT NAME REFERRED FOR URN

JAMES PAGET UNIVERSITY HOSPITALQUEEN ELIZABETH HOSPITAL (KING'S LYNN)NORFOLK AND NORWICH UNIVERSITY HOSPITAL

Does this Patient require Bariatric Chair Provision? Yes No Does this patients BMI suggest that they may not be able to receive sedation in primary Care? Yes No

This a common medical history form. This should be used in combination with a referral

form with an URN.

MEDICAL HISTORY FORM

(age 12 and over)

Before you begin a referral: Please ensure that you have read and understood the

referral guidelines; referrals not meeting these guidelines will be returned to you or the holder of your contract.

Make sure that you have the necessary attachments, such as radiographs, and, if this is an electronic form, that you

have acquired a unique reference number (URN). You can read guidelines, get a URN and check the status of any referral by visiting: www.dental-referrals.org

URN: ESX PLEASE ENTER THE URN FROM THE REFERRAL FORM. THIS FORM SHOULD BE SUBMITTED WITH THE REFERRAL FORM. ATTACH WITH A PAPER CLIP. PLEASE DO NOT STAPLE.

DO NOT LEAVE BLANK – PLEASE PLACE “NAD” IF REQUIRED – BLANKS FORMS WILL BE RETURNED

MEDICAL ALERT – Please note here anything of particular importance in the medical history and their impact on delivering care within a regular primary care setting.

DOES THE PATIENT HAVE / SUFFER FROM / CURRENTLY EXPERIENCING

RECEIVING TREATMENT FROM HOSPITAL DOCTOR OR CLINIC?

BLOOD OR BLEEDING DISORDER?

TAKING ANY PRESCRIBED / NON-PRESCRIBED MEDICATION

INFECTIOUS DISEASES (HEPATITIS)?

PREGNANT OR POSSIBLY PREGNANT?

LIVER DISEASE?

HEARING IMPAIRMENT?

SPEECH IMPAIRMENT?

COMMUNICATION PROBLEM?

CARRYING A MEDICAL WARNING CARD?

HEART DISEASE?

BRONCHITIS, ASTHMA OR OTHER CHEST COMPLAINT?

PACE MAKER

BLOOD PRESSURE?

VISUAL IMPAIRMENT?

LEARNING DISABILITY?

AUTISM?

OTHER?

PLEASE PROVIDE DETAILS OF ANY CONDITION INDICATED ABOVE INCLUDING ASSESSMENT OF SEVERITY AND IMPACT ON DELIVERING CARE

MEDICAL ALERTS

EPILEPSY

UNCONTROLLED HIGH BP

ALLERGIES

RHEUMATIC FEVER

REQUIRES AB COVER

IMPLANTS OF ANY KIND

PLEASE LIST ANY ALLERGIES HERE MOBILITY ISSUES WALKS UNAIDED WALKS AIDED WHEELCHAIR USER BEDRIDDEN

PLEASE PROVIDE DETAILS OF PATIENT’S SMOKING STATUS INCLUDING DAILY TOBACCO CONSUMPTION (E.G. CIGARETTES/DAY) AND UNITS OF ALCOHOL CONSUMED PER WEEK

PLEASE PROVIDE DETAILS OF ANY PRESCRIBED MEDICINES HERE. YOU MAY ATTACH FURTHER DETAILS TO THIS FORM AS REQUIRED

IOSN SEDATION FORM – MUST ACCOMPANY MINOR ORAL SURGERY FORM

URN: ESX TREATMENT COMPLEXITY GUIDANCE – NOT EXHAUSTIVE

[IF IN DOUBT OVER TREATMENT COMPLEXITY PLEASE SCORE THE HIGHER VALUE]

ROUTINE –single rooted extraction of 1 or 2 teeth, small soft tissue biopsy INTERMEDIATE –multi-rooted tooth extraction, surgical extraction without bone removal, apicectomy anterior tooth, COMPLEX –surgical extraction with bone removal, HIGH COMPLEXITY - Any treatment considered more complex than above or are multiples of the above

COMPLEXITY SCORE – CHECK ONE

ROUTINE INTERMEDIATE COMPLEX HIGH COMPLEXITY

The reason for referral is that I have been unable , or felt it inappropriate to treat under local anaesthesia alone because:

1. The patient is unable to co-operate adequately for me to treat them

2. The patient is too frightened to accept treatment

3. I have not been able to achieve satisfactory local anaesthesia

4. The patient gags uncontrollably when I attempt treatment

5. The patient has a severe phobia of needles

Other reason ( please specify )

Details of treatment attempted, inclusive of dates

MEDICAL & BEHAVIOURAL INDICATORS This information does not replace a full medical history which should be completed and attached to this referral

CHECK GRADE

No medical or behavioural indicator 1

Systemic disorders (not of severity to exclude sedation) that may be exacerbated by treatment: Fainting attacks/ epilepsy/ hypertension/ angina/ asthma/ other (please state)

2 3 4

Conditions that compromise ability to cooperate: Arthritis/parkinsonism/ multiple sclerosis/ other (please state) As a rule of thumb ASA II would generally be 2 or 3 and an ASA III would result in a grade of 4.

2 3 4

Gag reflex Behavioural difficulties

2 3 4

2, 3 or 4BRIEF NOTE OF PREVIOUS SEDATION HISTORY:Patient anxiety question – to be completed by the patient

If you went to your dentist for TREATMENT TOMMORROW, how would you feel?

Not anxious Slightly anxious Fairly anxious Very anxious Extremely anxious

If you were sitting in the WAITING ROOM (waiting for treatment) how would you feel?

Not anxious Slightly anxious Fairly anxious Very anxious Extremely anxious

If you were about to have a TOOTH DRILLED, how would you feel?

Not anxious Slightly anxious Fairly anxious Very anxious Extremely anxious

If you were about to have your TEETH SCALED AND POLISHED, how would you feel?

Not anxious Slightly anxious Fairly anxious Very anxious Extremely anxious

If you were about to have a LOCAL ANAESTHETIC INJECTION in your gum, above an upper back tooth, how would you feel?

Not anxious Slightly anxious Fairly anxious Very anxious Extremely anxious

or

or

How to send your referral to us:

Email us at: d.referrals@nhs.net

Post your referral to: Dental Referral Management Centre 6 The Offices Stannian Fold, Pool Lane Lymm, Warrington WA13 9AB

Fax your referral to: 0161 850 2123

For help, advice & support www.dental-referrals.org

Phone support See website for details

Please note that the fastest and most secure way to send your referral to us is via onlinesubmission. Please register online or contact us at d.referrals@nhs.net. Please only fax referrals that have no attachments and do not send duplicate fax and postal referrals.

If you want PDF forms to complete electronically, or you need more forms simply visit the website and select referral tools.

You will need a URN number for any referrals you are sending using your own printed or emailed forms. URNs are 10 digits and you can get up to ten at a time from the website.

Please talk to us. The best way to get immediate help and advice is to email us at d.referrals@nhs.net. We will normally get back to you within a few hours.

Cancer ReferralsPlease do not send any HSC205 referrals to our service. You should follow current protocol for your local oral and maxillofacial surgery department.

ORAL SURGERY GUIDANCE

Please note that extractions that are considered routine will be returned to you or the contractholder. Oral surgery services are offered at a range of providers both in secondary and primary care – please ensure that you have indicated a preferred hospital in case this option is needed. If a preferred hospital is not selected then we will, if indicated, send your referral to the nearest hospital to your patient’s home address.

Referrals accepted for: Management of cranio/facial/TMJ pain** Removal of symptomatic/carious buried roots

and fractured or residual root fragments Possible removal of impacted, ectopic or

supernumerary teeth – please consider anorthodontic opinion on these first

Possible exposure of teeth Minor, non suspicious soft tissue lesions/surgery Consideration of surgical endodontics Dento-alveolar trauma beyond the scope of

general practice Surgical procedures (including routine) on

medically compromised patients where treatmentin general practice would pose an unacceptablerisk – eg multiple antiplatelet agents; INR>4; IVbisphosphonates; history of head and neckradiotherapy; oxygen and nebuliser dependence;uncontrolled epilepsy; new onset jaundice; provenbleeding diathesis; serious adverse reaction to LA;trismus.

For procedures under GA where a full justificationof why treatment cannot be provided by any othermeans.

If you are requesting GA or sedation you must completean IOSN form.

**For TMJ referrals simple joint clicking is a not a reason for referral. Please also ensure that you detail the steps that have been taken in primary care including splints, exercises etc. Please see more details on the website.

Referrals are NOT accepted for:

Routine extractions and root removal Management of minor trauma including

avulsed teeth Routine procedures on low-risk patients e.g.

hypertension, warfarin – INR<4; steroids. Suspected cancer referrals – please refer

direct

Spreading infection and swelling in an unwell patient – refer urgently to A & E

If you have a patient with a lesion that you believe may be malignant do not use this referral form but contact the appropriate acute trust using their current

procedures.