Dental Referrals. DENTIST DETAILS * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### PATIENT DETAILS * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Email * Phone * (###) ### #### Reason for Referral * Anxiety/Phobia Pronounced gag reflex Needle phobic Surgical Procedure Prolonged or unpleasant treatment Other RELEVANT MEDICAL HISTORY * please give details of any medical conditions and medication DETAILS OF PREVIOUS DENTAL TREATMENT / ONGOING DENTAL TREATMENT /PREVIOUS SEDATION * BMI over 35 * Yes No What is the O.H. Status of the Patient * Good Satisfactory Poor Treatment Required * Teeth to be Treated * (Tooth notation / surfaces of fillings clearly marked) More than 3 fillings may need a second referral – sedation app. are time restricted Any Other Information * Please indicate if you will be forwarding any relevant X-Rays to reception@willowsdentalgroup.co.uk Yes No Thank you!
