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Patient details

Patient name * REQUIRED
Patient's address * REQUIRED
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Communication preference * REQUIRED

Referrer details

Name of referrer * REQUIRED
Referrer's address * REQUIRED

GP details

If not registered please type 'Not registered' for all fields
GP name * REQUIRED
GP practice address * REQUIRED

Referral information

e.g. extraction of tooth
e.g. not treatable pulpal/periapical pathology
e.g. close proximity to antrum/risk of oro-antral fistula
Has extraction been attempted for the tooth/teeth? * REQUIRED
Is this referral for a patient undergoing a private course of treatment? * REQUIRED

Medical history and patient associated modifiers

Medical conditions

Medications

Anticoagulants * REQUIRED
Bisphosphonate * REQUIRED
Immunosuppressive drugs * REQUIRED
Steroids * REQUIRED

Social history

Communication issue * REQUIRED
Cooperation issues * REQUIRED
Legal or ethical issues affecting care * REQUIRED
Oral risk factors * REQUIRED
Restriction accessing care * REQUIRED
Does the patient have a severe gag reflex and/or severe dental anxiety/phobia? * REQUIRED
Would you like to add/upload any additional information?
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    Imaging information

    Upload X-ray/clinical illustration (obligatory), or provide explanation below, as to why the X-ray/clinical illustration cannot be provided.
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    Max. file size: 64 MB.
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      Max. file size: 64 MB.

        Consent

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