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Oral Surgery Referrals

Allow our local specialist surgeons enhance your patients experience with expert care
Referrer details
Patient details
Teeth Requiring Treatment
RIGHT
UR8
UR7
UR6
UR5
UR4
UR3
UR2
UR1
LR8
LR7
LR6
LR5
LR4
LR3
LR2
LR1
LEFT
UL1
UL2
UL3
UL4
UL5
UL6
UL7
UL8
LL1
LL2
LL3
LL4
LL5
LL6
LL7
LL8
REASON FOR TREATMENT
Unrestorable (caries/fracture/roots)
Infection/Pain - patient does not want to save (all options discussed)
Apiceptomy
Other (please put full details in further information box below)
Confirm to NICE guidelines for third molar removal (Click here for guidance)
APPOINTMENT REQUIRED
Consultation only
Consultation and Treatment
Referral information
(antiplatelet/anticoagulants/bisphosphonate/steroid use; heart issues requiring ab cover; blood/bleeding disorders)
Tick the below box to confirm that an email has been sent to "INFO@DENCARECLINIC.CO.UK" with all relevant attachments including any photograph(s), radiograph(s), scan(s) & report(s), x-ray(s) and other such relevant document(s) together with the patient name and date of birth in the subject of the email to identify the patient?
Tick this box
Tick the below box to confirm all the information provided has been checked, is accurate and the patient has consented to share this information with The DenCare Clinic & Travel Vaccinations oral surgery referral pathway?
Tick this box
Send
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