"*" indicates required fields Patient detailsDate of referral * REQUIRED Patient name * REQUIRED MrMrsMissMsDrProf.N/A Title First Last Date of birth * REQUIRED Gender * REQUIREDMaleFemaleOtherPatient's address * REQUIRED Address Town / City / Village County Postcode Email addressPhone numberMobile preferred for SMS messagingCommunication preference * REQUIRED Phone Email Text/SMS NHS number * REQUIRED Case ID * REQUIRED Referrer detailsName of referrer * REQUIRED MrMrsMissMsDrProf.Rev. Title First Last Referrer's address * REQUIRED Address Town / City / Village County Postcode Referrer's email address (NHS email preferred) * REQUIRED Referrer's telephone number * REQUIREDGP detailsGP name * REQUIRED MrMrsMissMsDrProf.Rev. Title First Last Practice name / surgery * REQUIREDGP practice address * REQUIRED Address Town / City / Village County Postcode GP telephone number or email address * REQUIREDReferral informationRequest for treatment * REQUIREDe.g. extraction of toothReason for treatment/extraction * REQUIREDe.g. not treatable pulpal/periapical pathologyAssociate complexity * REQUIREDe.g. close proximity to antrum/risk of oro-antral fistulaHas extraction been attempted for the tooth/teeth? * REQUIRED Yes No If you answered 'no' to the previous question, please give reason whyPlease provide any supplementary information related to the tooth/teeth requiring extraction * REQUIREDIs this referral for a patient undergoing a private course of treatment? * REQUIRED Yes No Medical history and patient associated modifiersIntended referral * REQUIREDTreatment/advice * REQUIREDMedical conditionsPlease indicate patient's medical condition/s * REQUIREDBehavioural, mental and neurologicalBlood/haematologyCancer/neoplasmCardiovascular/circulatoryDigestive system/gastroenterologyEndocrine, nutritional and metabolic disorderKidney/genitourinaryMusculoskeletal/connective tissueNervous systemRespiratory systemOther (please specify below)If you answered 'other' to the above question, please provide further informationMedicationsAnticoagulants * REQUIRED No Yes, please provide further information below Further informationBisphosphonate * REQUIRED No Yes, please provide further information below Further informationImmunosuppressive drugs * REQUIRED No Yes, please provide further information below Further informationSteroids * REQUIRED No Yes, please provide further information below Further informationOtherSocial historyCommunication issue * REQUIRED No Yes, please provide further information below Further informationCooperation issues * REQUIRED No Yes, please provide further information below Further informationLegal or ethical issues affecting care * REQUIRED No Yes, please provide further information below Further informationOral risk factors * REQUIRED No Yes, please provide further information below Further informationRestriction accessing care * REQUIRED No Yes, please provide further information below Further informationDoes the patient have a severe gag reflex and/or severe dental anxiety/phobia? * REQUIRED No Yes, please provide further information below Further informationWould you like to add/upload any additional information? Yes No If yes, please upload files belowFile Upload Drop files here or Select files Accepted file types: jpg, png, gif, pdf, docx, Max. file size: 8 MB. Maximum file size - 8 mega bytes. Please provide relevant supplementary informationImaging informationUpload X-ray/clinical illustration (obligatory), or provide explanation below, as to why the X-ray/clinical illustration cannot be provided.Please attach radiograph files with the name and DOB of the patient clearly marked on the image.Date X-ray taken * REQUIRED DD slash MM slash YYYY File Drop files here or Select files Max. file size: 64 MB. File Drop files here or Select files Max. file size: 64 MB. Explanation why X-ray/clinical illustration cannot be provided ConsentConsent * REQUIRED I have patient consentI confirm that the patient (and/or carer/parent/guardian) has the capacity and is willing to make a voluntary and informed decision to consent to this referral being made and shared as necessary with those working for or on behalf of NHS England & NHS Improvement, and with all relevant providers.Consent * REQUIRED I have advised that NHS dental charges may applyI have discussed with the patient that IMOS treatment will be subject to NHS dental charges (Band 2), unless exempt.Consent * REQUIRED I have informed the patient that the IMOS service can provide treatment under local anaesthetic onlyI understand that if the patient requires sedation (GA, inhalation etc.), the referral will be rejected.CAPTCHADate MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.