University of Bristol Dental Hospital E-Referral For
Head and Neck Suspected Cancer referrals must be submitted via the Fast Track Office, either via Choose & Book (preferred method) or Email ubh-tr.fast-trackreferrals@
|PATIENT DETAILS |
|Surname: …………………………………….……………… First name: ……………………..……………… Date of Birth: ………………….……… |
|SECTION 1 - REFERRAL INFORMATION |
|URGENT ☐ ROUTINE ☐ SUITABLE FOR STUDENT TREATMENT ☐ (please tick) |
|If recommended for student treatment, please ensure patient is aware of potential wait for treatment |
|SECTION 2 - TRIAGE INFORMATION |
|BDH USE ONLY |ROUTINE | |
|INITIALS | |CLINIC | | |
|RADIOGRAPH |
|Is a diagnostically acceptable RADIOGRAPH included with this referral? |YES ☐ NO ☐ Reason if not……..……………………………………………. |
|CLINICAL REASON FOR REFERRAL. Please detail reason for referral and what you want us to do for your patient. |
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|PROVISIONAL DIAGNOSIS AND CURRENT TREATMENT PLAN IN ASSOCIATION WITH THIS REFERRAL. Please detail. |
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|RELEVANT PREVIOUS TREATMENT HISTORY. Please detail. |
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|SECTION 3 - ADDITIONAL INFORMATION |
|MEDICAL HISTORY - Please include significant hospitalisation, operations, ongoing treatment and smoking/drinking history as needed. |
|YES ☐, please detail. NONE ☐ |
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|MEDICATION - Please state type and dosage details. YES ☐, please detail. NONE ☐ |
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|ALLERGIES - Please state allergy and description of reaction, if known. YES ☐, please detail. NONE ☐ |
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|OTHER INFORMATION (E.g. Living arrangements, Legal guardian) |
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|PAEDIATRIC GENERAL ANAESTHETIC |
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|PATIENT DETAILS – Please enter patient identifier at top of each page. |
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|Surname: …………………………………….……………… First name: ……………………..……………… Date of Birth: ………………….……… |
|Justification for general anaesthetic: |
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|Teeth present: |Treatment requested: | |
| |CARIES |☐ |
| |ORTHO |☐ |
| |TRAUMA |☐ |
| |OTHER |☐ ………………………………………………. |
|DETAILED MEDICAL HISTORY FOR GENERAL ANAESTHETIC REFERRAL |
|CVS |Heart disease, hypertension, syncope, angina, rheumatic fever |YES ☐ NO ☐ |
| |Bleeding disorder, anticoagulant, anaemia |YES ☐ NO ☐ |
|RS |Asthma, bronchitis, TB, other chest disease |YES ☐ NO ☐ |
|GI |GI disease |YES ☐ NO ☐ |
| |Hepatitis, jaundice |YES ☐ NO ☐ |
|GU |Renal disease |YES ☐ NO ☐ |
|CNS |Epilepsy, convulsions, disabilities or learning difficulties |YES ☐ NO ☐ |
|LM |Bone or joint disease |YES ☐ NO ☐ |
| |Disease or other endocrine disease |YES ☐ NO ☐ |
| |Skin disease |YES ☐ NO ☐ |
| |Any other disease (including congenital abnormalities) |YES ☐ NO ☐ |
| |Relevant family MH |YES ☐ NO ☐ |
| |Allergies e.g. Penicillin |YES ☐ NO ☐ |
| |Recent or current drugs/medical treatment |YES ☐ NO ☐ |
| |Previous operations or serious illness |YES ☐ NO ☐ |
| |Recent travel abroad |YES ☐ NO ☐ |
| |Are they under review or treatment at any other hospital/dentist? If yes, please detail. |YES ☐ NO ☐ |
|SICKLE CELL DISEASE AND THALASSAEMIA |
|Indian and Afro-Caribbean patients should have a test for sickle haemoglobin which must be done before attending the General Anaesthetic Department. |
|Eastern Mediterranean patients should have a test for thalassaemia |
|If your patient requires testing for sickle cell disease or thalassaemia, please refer the patient to their GP. |
|If you have any problems, please contact the Admissions Manager on 0117 342 4385. |
|If known, please indicate patient sickle cell status: Negative ☐ Positive ☐ Trait ☐ |
|Please indicate if you wish to be consulted if changes to requested treatment plan are deemed advisable at BDH. i.e. Balancing/Compensating. |
|YES ☐ NO ☐ |
|Appointments for our pre-clerking clinic for children under the age of 16 who require a general anaesthetic can be made by telephone on the following telephone |
|number: 0117 342 4385. |
|May we remind you of The Maintaining Standards guidelines which state that: |
|Clear justification for the use of general anaesthesia together with the details of the relevant medical and dental histories of the patient must be contained in |
|this referral document. The referring dentist must retain a copy of this. Paragraph 4.18 GDC Maintaining Standards, revised November 2001. |
|SECTION 4 – FULL PATIENT DETAILS |SECTION 5 – PATIENT PARENT/GUARDIAN, SCHOOL NURSE OR CARER DETAILS (if |
| |applicable) |
|Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Dr ☐ Other ☐ |Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Dr ☐ Other ☐ |
|Male ☐ Female ☐ NHS Number: |Relationship to patient: |
|Surname: |Surname: |
|First name: |First name: |
|Date of Birth: |Date of Birth: |
|Address: |Address: |
|Town/City: |Town/City: |
|Postcode: |Postcode: |
|Telephone Number: |Telephone Number: |
|Mobile Number: |Work Number: |
|E-mail Address: |E-mail Address: |
|SECTION 6 - REFERRER DETAILS |SECTION 7 - PATIENT GP DETAILS (if not the referrer) |
|Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Dr ☐ Other ☐ |Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Dr ☐ Other ☐ |
|Surname: |Surname: |
|First name: |First name: |
|Job Title: |Practice Name: |
|GDC/GMC Number: |Practice Address: |
|Practice Name: | |
|Practice Address: |Town/City: |
|Town/City: |Postcode: |
|Postcode: |Telephone Number: |
|Telephone Number: |E-mail Address: |
|E-mail Address: | |
|SECTION 8 - COMMUNICATION & SPECIAL REQUIREMENTS |
|Does the patient communicate in a language or mode other than English? YES ☐, please detail. NO ☐ |
|Is an interpreter required? YES ☐, please detail. |
|NO ☐ |
|Does the patient have any special requirements? YES ☐, please detail. NO ☐ |
|SECTION 9 - PATIENT CONSENT TO REFERRAL AND ASSOCIATED TREATMENT |
|Has the patient understood and consented to the referral? YES ☐ NO ☐ |
|SECTION 10 – CONFIRMATION AND SIGNATURE OF REFERRING PRACTITIONER |
|I confirm that this patient referral meets the current referral guidelines as issued by the Bristol Dental Hospital. (Referral guidelines are available on the BDH |
|website). I understand that incomplete and/or inappropriate referrals will be returned for revision and may delay patient treatment. Please tick to confirm. ☐ |
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|Print Full Name:………………………………………………………………………………………………… Date:…………………………................. |
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|Signature: ……………………………………………………………………………… |
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Please return fully completed forms to: Patient Access Team, Bristol Dental Hospital, Chapter House, Lower Maudlin Street, Bristol, BS1 2LY. Call Centre Tel: 0117 342 4422.
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