Referrals - Rose Lane Dental Practice

Phone
This field is for validation purposes and should be left unchanged.
Patient Details
Patient Name*
First Last
Patient Date of birth*
Day
Month
Year
Patient Address*
Address Line 1 Address Line 2 City County Postcode
Patient Contact Phone Number*
Patient Email
Type of referral
I am referring for*
- Implants – Paul Swanson BDS MFGDP(UK) PG Cert (Sed) DipImpDent RCS (Eng) MSc (Implant)
- Implants – Abd Kouzali BDS, RCS(Eng)
- Implants – Ashish Patel BChd MSc(restorative ) DipImpDent MFDS RCSEd
- Restorative – Steven Barber BDS MFDS RCPS FDS (Rest Dent) RCPS
- Periodontal Team
- Periodontal – Ian Dunn BCHD MFGDP (UK) MSC (Perio)
- Periodontal – Ruth Crook BDS MSc (Perio) Dundee
- Periodontal – Laura Kwasnicki BChD
- Endodontic Team
- Endodontics – Michael Dodd BDS (hons), MFDS RCS (Edin) DDSc (Endo), MEndo RCS (Edin), PGCert HE.
- Endodontics – Ian Bowles, BChD, MFGDP (UK), DipRestDent RCS(Eng), MSc (Endo)
- Orthodontics – Andrew Garry BA, BDentSc, MFDS, M.Orth (RCS Ed), DDSc
- Oral Surgery – Abd Kouzali BDS, RCS(Eng)
- Radiography
- IV Sedation – Catherine Kwasnicki
- Inhalation Sedation – Catherine Kwasnicki
Implant Referral*
- Opinion Only
- Bone Grafting / Sinus Elevation / Soft Tissue Correction
- Surgical Placement / Uncovering
- Full Case
Oral Surgery*
- Retained Roots
- Apicectomy
Charting
Teeth to treat*
- UR8
- UR7
- UR6
- UR5
- UR4
- UR3
- UR2
- UR1
- UL1
- UL2
- UL3
- UL4
- UL5
- UL6
- UL7
- UL8
- LR8
- LR7
- LR6
- LR5
- LR4
- LR3
- LR2
- LR1
- LL1
- LL2
- LL3
- LL4
- LL5
- LL6
- LL7
- LL8
Radiograph*
- CBCT
- OPG
Reason for referral and clinical justification radiograph*
If sectional view requested please state 4 teeth of most importance*
CBCT Referral Details
Define the anatomical area that the scan should cover*
What information do you want the dental CBCT examination to provide?*
Patient to wear stent provided by dentist ?*
- Yes
- No
Positioning of splint*
- I confirm the patient is competent in positioning splint
Due to the many different types of radiographic stents, it is essential that you ensure that your patient is competent in positioning it to your specifications.
IRMER
IRMER referrer/operator*
- I am the IRMER referrer/operator. I am adequately trained to report on my patient’s scan. To comply with the IRMER 2000 regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We advise that all CT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology.
Further Details
Relevant Medical History & Current Medications
Smoker?*
- Yes
- No
Case History*
Attachments
Drop files here or

Accepted file types: jpg, jpeg, png, gif, Max. file size: 15 MB, Max. files: 6.
Please send any relevant radiographs, not just most recent
Dentist Details
Dentist Name*
First Last
GDC Number*
Dentist Email*
Dentist Phone
Practice Address*
Street Address Address Line 2 City Postcode
Confirm
I have completed the form accurately and understand it will be processed in line with the privacy policy
I have ensured all details are completed accurately. All boxes contain the correct information requested. I understand any mistakes can result in the referral not being processed efficiently and delays to contacting the patient.

Referral Form

Patient Details

Type of referral

Charting

CBCT Referral Details

IRMER

Further Details

Dentist Details