Broadwood Dental

Referral Form

Patient Referral Form

Our clinic is committed to maintaining a rapid and highly responsive patient care pipeline.

All incoming referrals are thoroughly reviewed within 24 hours of receipt, and patients are actively contacted within the subsequent 48 hours to coordinate their initial appointments.

Furthermore, we ensure seamless communication and continuity of care by compiling and dispatching formal clinical letters within 48 hours of completed treatment.

Step1

1. Referring Practice

Details of the dentist and practice making the referral

Practice Name

Referring Dentist (Full Name)

GDC Registration Number

Practice Telephone

Practice Email Address

Practice Address (inc. postcode)

Step2

2. Patient Details

Personal information of the patient being referred

First Name

Last Name

Date Of Birth

NHS Number

Patient Telephone

Patient Email

Step3

3. Referral Details

Clinical reason and nature of referral being requested

Reason For Referral

Surgical Extraction

Wisdom Tooth Extraction

Canine Exposure

IV Sedation

Dental Implant

Extraction

Simple Restorative

Other

Tooth/Teeth Involved (Palmer or FDI notation)

Clinical Findings And Reason For Referral

Previous Treatment Relevant To This Referral

Step4

4. Medical History

Include all conditions and medications relevant to surgical treatment

Relevant Medical History

Current Medications (Name & Dose)

Known Allergies

Anticoagulants/Antiplatelets

None

Warfarin

Apixaban

Rivaroxaban

Dabigatran

Aspirin

Clopidogrel

Dual antiplatelet

Bisphosphonates/Antiresorptives

None

Oral bisphosphonate

Rivaroxaban IV bisphosphonate

Denosumab (Prolia / Xgeva)

Step5

5. Radiographs

Upload or attach relevant imaging — OPG, periapical, or CBCT as appropriate.

Note: Radiographs are required for all extraction and surgical referrals. Referrals without appropriate imaging may be returned. An OPG is preferred for wisdom tooth and canine cases.

Radiographs

Step6

6. Consent & Additional Notes

Patient Consent For Referral

Patient has been informed and consents to this referral

Patient unable to consent — details provided in notes below

Any Other Relevant Information

Consent for storing submitted data

By submitting this form the referring dentist confirms the patient has consented to referral and that the clinical information is accurate and is giving permission to store and process this data. Referrals are reviewed within 24 hrs.

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