Queensway Dental Oral Surgery Referral Form

In accordance with policy referral protocols that can be found here.

(Please note we only manage ASA I and II Patients. ASA III may be suitable, but their care will be provided by exception – if unsure please contact us to discuss or refer to an appropriate secondary care service.)

NB: Please note this is not primarily a sedation service - for straightforward extractions on anxious patients please refer to the local sedation service. Please include ASA score, ie ASA1 and II (III by exception)

Before you submit the referral please tick...(*To be completed by the referring dentist)

• I have explained to the patient the reason for referral and the choice of provider which has been agreed by the patient.
• I have explained to the patient that their first appointment will be for assessment only and to bring along an up to date prescription (if applicable).
• I have made the patient aware of any other dental care required to be managed by the referring practice.
• I have read and understood the referral guidelines for referrals of this type and have included appropriate x-rays (or where not included have explained reason), medical history and medication