Referrals - Springfield Dental

Referrals

This form is for use by dentists to refer patients to the practice

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

Patient Details

Patient Name*

First Last

Patient Date of birth*

YYYY

Patient Address*

Address Line 1 Address Line 2 City County Postcode

Patient Contact Phone Number*

Patient Email

Type of referral

I am referring for*

Implant Case

Cosmetic Case

Oral Surgery

Invisalign

Root Canal Treatment

Hygiene

OPG / Extra-Oral Bitewings

Cone Beam CT

Implant Referral*

Opinion Only

Surgical Placement / Uncovering

Full Case

Oral Surgery*

Retained Roots

Apicectomy

Other

Hygiene*

Routine S/P

Full Mouth Disinfection

Other

IV sedation required

Yes

Charting

Teeth to treat*

UR8

UR7

UR6

UR5

UR4

UR3

UR2

UR1

UL1

UL2

UL3

UL4

UL5

UL6

UL7

UL8

LR8

LR7

LR6

LR5

LR4

LR3

LR2

LR1

LL1

LL2

LL3

LL4

LL5

LL6

LL7

LL8

Radiograph or Image

Accepted file types: jpg, gif, tif, png, jpeg, Max. file size: 128 MB.

X-ray / CBCT Referral Details

Reason for referral and clinical justification for X-ray / CBCT scan*

Upper Arch Scan*

No Scan

Full Arch

Sectional

Lower Arch Scan*

No Scan

Full Arch

Sectional

If sectional view requested please state 4 teeth of most importance*

Define the anatomical area that the scan / x-ray should cover*

What information do you want the dental CBCT examination to provide?*

Patient to wear stent provided by dentist ?*

Yes

Positioning of splint*

I confirm the patient is competent in positioning splint

Due to the many different types of radiographic stents, it is essential that you ensure that your patient is competent in positioning it to your specifications.

IRMER

IRMER referrer/operator*

I am the IRMER referrer/operator. I am adequately trained to report on my patient’s scan. To comply with the IRMER 2000 regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We advise that all CT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology.

Referral Details

Patient Complaint / Reason for Referral*

Relevant Medical History

Dentist Details

Dentist Name*

First Last

GDC Number*

Dentist Email*

Referring Practice*

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