REFERRING PRACTITIONER |
| Name |
|
| Address |
|
| Telephone |
|
| Fax |
|
| Mobile |
|
| Email |
|
PATIENT DETAILS |
| Name |
|
| Address |
|
| Tel (home) |
|
| Tel (work) |
|
| Mobile |
|
| Email |
|
| Date of Birth |
|
| Private Health Insurance? |
Yes
No |
| Insurance Company |
|
HISTORY |
| Oral Condition |
Excellent
Above Average
Average
Below Average
Poor |
| Muscosa |
Normal
Abnormal |
| Mucosa Details |
|
| Teeth Missing |
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8 |
|
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8 |
| Pain |
O
+
++
+++ |
| Swelling |
O
+
++
+++ |
| Vital |
Yes
No |
| PA Lesion |
Yes
No |
REFERRAL DETAILS |
|
|
| Other Referral |
|
| Reasons For Referral |
|
| I would like to be present during the consultation/treatment |
|
Yes
No |
| I would like the dentist to contact me to discuss the case |
|
Yes
No |
| Relevant Medical History |
|
| Has the patient been given an estimate of our fees? |
|
Yes
No |
| Other Relevant Information |
|
