Patient Referral

Question 1

Referrer’s details?

Answer 1

Name of referring dentist (essential)
Address (essential)
Telephone (desirable)
Email address (optional)

Question 2

What to write about the person and /or department you are referring the patent to?

Answer 2

Name
Address

Question 3

What patient details to include on referral?

Answer 3

Name
Address
Telephone
Dob

Question 4

What do about the pts medical practitioner to include on referral form?

Answer 4

Name
Address
Telephone number

Question 5

MH to include in the referral?

Answer 5

Revelevtn medical
Medications
Allergies
GA adverse reaction

Question 6

Social history to include in the referral?

Answer 6

Smoking
Drinking
Ability to attend appointments

Question 7

FH to include in the form?

Answer 7

Familial or genetic contribution

Question 8

Reason for referral?

Answer 8

Extra oral examination

Intraoral examination

Radiographic examination

Diagnosis or differential diagnosis

Advise or treatment sought

Indicate the urgency of the referral

Question 9

What to include in the referral - enclosures?

Answer 9

Radiographs

Study models

Photographs

Dentures

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