Patient Referral Form

1. Referring dentist

2. Practice

3 Address

4 Telephone

5 Email

6 Patient

7 Title

8 Mobile

9 D.O.B

10 Address

11 Telephone

12 Mobile

13 Reason for referral

14 Does the patient have any up-to-date records available? (radiographs)
Not SureYesNo

15 If yes, are they included?
Not SureYesNo

16 If not, can they be made available?
Not SureYesNo

Medical Questionnaire

17 Has the patient ever had or does he / she suffer from:
Heart TroubleAsthmaLiver DiseaseDiabetesBleeding TendenciesHigh Blood PressureChest TroubleKidney DiseaseEpilepsy/ ConvulsionsSleep Apnoea

18 Is the patient on any medications or drugs?
Not SureYesNo

19 If yes, please specify

20 Is the patient ALLERGIC to anything?
Not SureYesNo

21 If yes, please specify

22 Has the patient ever had a previous anaesthetic?
Not SureYesNo

23 If yes, please specify with dates

24 Has the patient or any family member ever had a problem with anaesthetic?
Not SureYesNo

25 If yes, please specify

26 Does the patient smoke?
Not SureYesNo

27 Has the patient used cannabis in the last 4 weeks?
Not SureYesNo

28 Has the patient ever used drugs intravenously?
Not SureYesNo

29 How many units of alcohol does the patient drink per week?

30 Is the patient pregnant?
Not SureYesNo

31 Any other relevant medical or dental history:

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