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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