Patient Referral Form

Referring dentist

Practice

Address

Telephone

Email

Patient

Title

D.O.B

Address

Telephone

Mobile

Reason for referral

Does the patient have any up-to-date records available? (radiographs)

 Yes No

If yes, are they included?

 Yes No

If not, can they be made available?

 Yes No

Medical Questionnaire

Has the patient ever had or does he / she suffer from:

 Heart Trouble Asthma Liver Disease Diabetes Bleeding Tendencies High Blood Pressure Chest Trouble Kidney Disease Epilepsy/ Convulsions Sleep Apnoea

Is the patient on any medications or drugs?

 Yes No

If yes, please specify

Is the patient ALLERGIC to anything?

 Yes No

If yes, please specify

Has the patient ever had a previous anaesthetic?

 Yes No

If yes, please specify with dates

Has the patient or any family member ever had a problem with anaesthetic?

 Yes No

If yes, please specify

Does the patient smoke?

 Yes No

Has the patient used cannabis in the last 4 weeks?

 Yes No

Has the patient ever used drugs intravenously?

 Yes No

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

Is the patient pregnant?

 Yes No

Any other relevant medical or dental history: