Oral Surgery Referral Form

Oral Surgery Patient Referral Form

Oral Maxillofacial Surgery Consultant
Name of the Patient*

First NameLast Name
Patient’s Date of Birth*

MonthDayYear
Patient’s Gender*
Patient’s Phone:*

Area CodePhone Number
Patient’s E-mail*
example@example.com
Patient’s Address:*

Home Name/Number

Street Address

Town/CityCounty

Post Code
Marital Status*
Type of Referral*

UrgentRoutineReview
Medical History*
ASA Status*

1 Healthy2 Mild Medical Condition3 Multiple Medical Conditions4 Life-threatening Conditions
Taking any medications, currently?*

YesNo
If yes, please list it here:
Chief Complaint*
Reason for Referral*

PericorinitisCurrent decayCurrent infectionPainSwellingPeriapical pathologyPreventative (no current symptom)CystOther
Diagnosis:*
Tentative diagnoses
Treatment Required:*
Please list treatments required etc.
Location of cyst
Size of the cyst
in mm. diameter
Is the cyst is of dental origin

YesNo
Type of cyst

PeriapicalDentigerousAmeloblastomaOdontogenic keratocystic tumourOther
Please enumerate the teeth that need extraction;
Use only FDI teeth numbering system
Tooth presentation

ImpactedPartially EruptedRetained/Buried rootsBroken Down
Does Patient have an OPG?*

YesNo
Would you like us to do an OPG xray?

YesNo
File Upload

Please upload OPG (annotated with name, DOB and date taken).
Cancelof
Clinic Name:*
Referrer’s Name:*

First NameLast Name
GDC no.*
Phone:*

Area CodePhone Number
E-mail*
example@example.com
Clinic Address:*

Street Address

Street Address Line 2

Town/CityCounty

Postal / Zip Code
Please verify that you are human*
Oral Surgery Tariff with Consultant Oral Surgeon

(Please advise the patient of the fees before submitting this referral form)

Consultation with Oral Surgeon - £180

Biopsy - Varies (+*£500 lab fee)

Apicectomy - from £600

Impacted tooth removal - £500

Coronectomy - £450

Orthodontic Tooth removal (Minimal trauma) - £425

Implant-ready Tooth removal (Minimal trauma) - £425
Should be Empty:

Oral Surgery Patient Referral Form