Oral Surgery Referral Form Date of referral



Oral Surgery Referral Form Date of referral
 Birmingham, Solihull, Black Country
Managed Clinical Networks
Oral Surgery Referral Form
Date of referral
Items marked with * are considered essential - a referral will not be accepted without these details.
Section Re:
A - Patient details
First names*
Date of birth*
Yours sincerely
Preferred contact number
Section B - Referring Practitioner details
practitioner name*
NHS number
GDC/GMC number*
Practice name
Practice address*
Practice phone number
Email address
General medical practitioner details (if different to above)
Phone number
Section C - Medical history*
Has the patient ever experienced or been diagnosed with the following (Place a X or
details below as necessary)
Bleeding/Clotting Disorder
Heart Condition
Chest Condition
and provide
Sickle cell anaemia
(for paediatric
GA cases only)
Allergies (please state)
Other (please state)
Additional medical history information including all medications
(continue on separate sheet if necessary)
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No relevant medical history
Section D - Social history
Please include any information that modifies this patients treatment needs - see guidance notes
Section E - Diagnosis/reason for referral*
Please enter diagnosis if known or details of reason for referral (see guidance notes)
Section F - Type of referral*
Surgical removal of retained roots
Surgery as part of an orthodontic treatment plan
Surgical removal of wisdom tooth
Soft tissue surgery including biopsy
Surgical removal of other tooth
Implant treatment (complying with NHS guidelines)
Other pathology
(enter details in section E)
(see guidance notes)
Tooth apex surgery
Other (enter details in section E)
(please include covering letter from orthodontist)
Please indicate requested mode of anaesthesia
(Note that indicating general anaesthesia or sedation does not guarantee provision)
Local anaesthesia only
Intravenous sedation
Inhalation sedation
General anaesthetic
For extractions, please indicate below the teeth/roots to be removed
For exposures, please indicate tooth and prefered approach (open/closed)
Permanent dentition
Primary dentition
8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8
Preferred Consultant?
If yes please name
Section G - Radiographs* Radiographs are required for some referrals, see guidance notes
Have you enclosed any radiographs?
If yes
If the radiographs are electronic, please send to appropriate email address, see guidance notes.
Please do not include photocopies or paper print outs as these cannot be accepted.
Please do not include bite wing radiographs for adult oral surgery referrals.
Date radiograph taken
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Produced by Clinical Photography and Graphic Design Tel: 0121 466 5107 Ref: 44321 19.10.15
Oral Surgery MCN Referral Form Guidance Notes for Practitioners
Thank you for using the new minimum data set referral form for your oral surgery referral and hope
you find it user friendly.
Please don’t use this form for suspected oral cancer referrals, use your existing rapid access
referral pathway.
The form is in PDF format that can be completed electronically to save time. The notation of teeth related
to the referral will have to be entered by the referring practitioner by hand. There is the opportunity to
provide feedback to the MCN about this form and changes will be made if necessary. Any feedback will
be discussed at the next MCN meeting in December 2015 with the aim being that referrals will only be
accepted on this form from an agreed date following this. The goal is to have a fully electronic version
with drop down menus in due course.
The aim of this form is to streamline the referral process across the MCN, hopefully improving access to
these services for the patient and also allowing the collection of data relevant to the new commissioning
guidelines that can be used to inform future commissioning decisions. There will be no change in
acceptance of referrals at secondary care providers until sufficient data has been collected and discussed
with commissioners through the MCN.
These guidance notes are designed to assist you in completing the form so that it is accepted without
the need for further information, thus facilitating the patient referral.
• There are a number of Oral or Oral and Maxillofacial Surgery units in the MCN area that will accept
referrals. A list of units is included in the appendix.
• Social History: Please include here such things as communication difficulties including the need
for translation services and the patient’s first language. Also include any mobility difficulties.
- You may also wish to enter details about patient anxiety here including any assessment you
have made of this.
• Diagnosis / Reason for referral:
- Please enter a diagnosis. If this is unknown then enter details of the signs and symptoms related to the
reason for referral and any investigations you have completed and details of discussions you have had
with the patient.
- With TMD it is expected that initial management has been offered by the referring practitioner
including reassurance, simple exercises and provision of a soft bite raising appliance where appropriate.
This management regime should have been in place for at least 3 months before referral to a secondary
care provider unless there are concerns about the primary diagnosis.
• Radiographs:
- For adult referrals for removal of teeth or retained roots except wisdom teeth and for requests for
apical surgery then a diagnostic quality radiograph of each tooth should be included with the referral,
this can be an OPG for multiple extractions. For wisdom teeth if an OPG has been taken then it should
be included with the referral.
This approach will enable some patients to be sent direct to treatment rather than have to wait for an
initial consultation appointment.
- A list of email accounts for receipt of radiographs is included in the appendix.
Please include the patients name, DOB and NHS number with the email to ensure the referral
and radiographs are linked.
Thank you again for adopting this new referral process
Please feedback any problems and potential improvements to the Oral Surgery MCN chairman
via the administrator [email protected]
Mike Murphy
Oral Surgery MCN Chairman
August 2016
5 Mill Pool Way, Edgbaston,
Birmingham, B5 7EG
Wolverhampton Road,
Wolverhampton WV 10 0QP
New Cross Hospital
0121 553 1831 0121 507 3221 [email protected]
Lyndon, West Bromwich B71 4HJ
Lode Lane, Solihull B91 2JL
Moat Road, Walsall, WS2 9PS
Sandwell General
Solihull Hospital
Walsall Manor
Mr Daniel Saund
Mr Nicholas Whear
Mr Luis Bruzual
Mr Prav Praveen
Mr N Grew
Mr S Shetty
Mr K Rehman
Mr Nick Pigadas
Mr N Whear
01922 721172
Ext 7447
[email protected]
Mr Nick Pigadas
Mr S Shetty
0121 424 2000 0121 424 4290 [email protected] Mr Keith Webster
Mr Rhodri Williams
[email protected]
01384 456111
[email protected]
Ext 5406
Russells Hall Hospital Pensnett Road, Dudley DY1 2HQ
[email protected]
Ext 5962
0121 627 2000 0121 371 5027 Ring to request
[email protected]
Ext 5405
Mr Jason Green
Mr Rhodri Williams
Mr Andrew Monaghan
Medical Lead
Referrals WITH x-rays (jpeg
Michael Murphy
format only): [email protected];
Referrals WITHOUT x-rays:
[email protected]
Queen Elizabeth
Mindelsohn Way, Edgbaston,
Hospital Birmingham Birmingham B15 2GW
01902 307999
0121 466 5000 0121 466 5555
(Waiting list
office for
general queries)
[email protected]
Birmingham Dental
0121 554 3801 0121 507 4311
Dudley Road, Birmingham B18 7QH
Email Address for Receipt
of Radiographs
Birmingham City
Dept Phone
Steelhouse Lane, Birmingham B4 6NH 0121 333 9999 0121 333 9352 Ring to request
Oral/Oral and Maxillofacial Surgery Units
Children’s Hospital
Appendix: List of Oral or Oral and Maxillofacial Surgery Units in the MCN Area

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