Minor Oral Surgery Referrals

Patient name

Patient address

Patient postcode

Patient date of birth

Patient telephone

Patient email

Full comprehensive medical history (inlcude alcohol intake & recreational drug use)

Patient medication

Smoking status
SmokerNon Smoker

Tooth/teeth to be extracted

IV Sedation Required? (If 'Yes' please include Height / Weight / BMI)

Referring Dentist Name

Referring Practice

Referring Practice Address

Referring Practice telephone

Contact email

Diagnostic X-rays (these must be attached) 5mb limit per file. Jpg, Png or Pdf accepted

Additional Radiographs

Additional Radiographs

Additional Radiographs

Additional Radiographs