Oral Surgery Referral

01903 491888

We are committed to providing exceptional minor oral surgery in partnership with our referring dental professionals. Our team provides a full scope of oral and dental surgical services. Every patient is treated with the highest level of clinical expertise, compassion, and respect for your ongoing treatment plan.

Image of dentist performing oral surgery

Oral Surgery Referral Form

Please complete the form below to refer patients.

*Indicates required field

Patient details

Address

Postcode

Date of birth

Contact number

Email

Treatment required Treatment required Surgical extraction Wisdom tooth extraction Frenectomy Canine traction surgery Impacted canines Extraction of supranumerary teeth Coronectomy Root rests Operculectomy Crown lengthening

Other (Please indicate in which area(s) treatment is required)

Please give details of the area(s) requiring treatment

Short summary of the case

Medical history

Radiographs included Radiographs included Yes No

New Field New Field OPG Bite wings Peri-Apical CBCT

File name to include referring dentist name, patients initials and patient DOB File InputNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, png. Max. file size: 1 MB

Will the patient benefit from sedation? Will the patient benefit from sedation? Yes No

Is your patient a regular attender to the hygienist? Is your patient a regular attender to the hygienist? Yes No

If 'yes', frequency of hygiene attendance? If 'yes', frequency of hygiene attendance? Never 1 per year 2 per year 3 per year 4 per year

Referring dentists details I have explained the need for referral and obtained my patient's consent for the treatment to be carried out.

GDC Reg No.

Practice name

Practice address

Postcode

Practice Email

Practice contact number

Additional comments

Practitioner Authorisation and Responsibility Statement

I confirm that:

The patient has been examined by me and is fit for oral surgery assessment
All relevant clinical information provided is accurate to the best of my knowledge.

By submitting this referral, the referring dentist acknowledges that:

The practice will assess the patient and recommend treatment based on clinical findings and suitability.

Final treatment planning decisions rest with the treating dentist in accordance with professional standards.

The referring dentist retains responsibility for the patient’s routine dental care.

The practice accepts no liability for pre-existing dental conditions or incomplete information provided at the point of referral.