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

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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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