Docklands Dental Referral Centre - Align and Smile
| Docklands Dental Referral Centre |
|NHS REFERRALS ( Orthodontics ( Oral Surgery PRIVATE REFERRALS (Ortho( Endo(MOS(Implants |
Patient details NHS Number………..…………...........
Title…………..First Name……………………..…………..................
Last Name……………………….……………….…………................
D.O.B………………………………………………………..................
Address……………………………………………………...................
……………………………………………………………….................
……………………..Post Code…….………………………...............
Tel - Home/work………………………………………...….................
Mobile……….……………………………………………….…............
Email………………………………………………………...................
Relevant Medical History………………………………………..........
.......…………………………………………………….........................
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Practice stamp
Other information
← Nervous/phobic patient
← Difficulty with local anaesthesia
← I would like to visit for joint treatment planning
Your appointment has been made and 48 hours notice is required to move or cancel it:
Date: ............/................./.................. Time: ...................................
PRIVATE REFERRALS: 020 7538 9990 info@alignandsmile.co.uk
NHS REFERALS: 020 7538 9991 docklands.dentalcentre@
Fax line: 020 7538 9996
How to find us by car (metered street parking available)
Approach the Isle of Dogs from Aspen Way. Pass Majestic Wines, IBIS Hotel and the first traffic lights.
Turn left at the second traffic lights and you will see us in front of the mini roundabout ahead.
London Underground: Canary Wharf Station (Jubilee Line), 10 mins walk towards Radisson Hotel
Buses: D6 (Aspen Way 3 mins) D8( Bllillingsgate 7 mins)
DLR station: Blackwall
Private Endodontics
← Root canal treatment on
← Re-root canal treatment on
NHS Oral Surgery
Impacted third molar within NICE Guidelines :
← recurrent pericoronitis or a single bout
← caries/perio/resorption of tooth or adjacent tooth
← pulpal or periapical pathology/cyst/fracture/cellulitis
← Other surgical extraction ( Exposure - unerupted tooth
( Removal of supernumerary ( Other ( see notes below)
NHS Orthodontics available to under 18s with at
least ONE of the following ticked and good oral hygiene:
( Crowding – any maligned contact point > 4mm
( Overjet > 6 mm but < = 9mm ( If >9mm ref to hospital)
( Reverse Overjet 1-3.5mm with reported speech or
masticatory difficulties (If > 3.5 mm ref to hospital)
( Impacted tooth ( Supernumary ( Hypodontia
( Anterior Open Bite 4 mm + ( Traumatic Overbite
( Cross bite with 2 mm or more displacement
Tooth/Teeth
Clinical Notes
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Key NHS Checklist
Please tick all of the following before making an NHS referral:
( FP17RN enclosed
( Patient informed of importance of
attending appointments
( Oral Hygiene of s sufficient standard
for orthodontics
( Patient notified that sedation or GA are
not provided for minor oral surgery
Private Oral Surgery & Implants
← Any NON NHS minor oral surgery under LA
← Implant referral
Please select one of the following for implant referrals:
← I will restore implant if provided
← Please also restore implant if provided
Private Orthodontics available to adults or under 18s who do not meet ANY NHS criteria.
Tick as many as required.
( Functional problems ( Cosmetic problems
( Orthodontics prior to other treatment
( Invisalign ® or Clearstep ® ( Lingual orthodontics
Dentist Name: ................................................Dentist’s signature: ............................................... Date: ........................
*Referral services at Docklands Dental Referral Centre maybe provided by self employed dentists, specialists or external organisations
(..........................................................................................................................................................................
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