ROI Patients
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Make a referral

To refer a patient to South Down Clinic, simply complete and submit the referral form below.

Please include all relevant clinical information regarding this case, and remember to attach any x-rays if relevant.

After reviewing, we will contact the patient to introduce ourselves and arrange an appointment. We will also keep you fully updated on progress throughout.

South Down Dental Clinic

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Referral Form

Choose referral

Type of referral *

Choose a treatment(s)

Final restoration to be placed by:

IV Sedation

The reason for referral is that I have been unable, or felt it inappropriate to treat under local anesthesia alone because:
Please indicate the patient's ASA Status (ASA Physical Status Classification System)
Please confirm you have provided written and verbal pre/post-operative instructions for sedation

CT Scanning

Scan details - region of interest

Mandible (FOV)
Maxilla (FOV)
Mandible and Maxilla
Tooth notations for smaller fields of view (5 x 5)
Additional scan requirements
Align with:
Please tick the more appropriate statement
Format required by referrer
Transfer of CBCT data
Third party software requirements

Referring dentist details

Patient details

NHS or Private? *
Does patient smoke?
Does patient consume alcohol?
Does the patient have any relevant medical history?

Medical History - Private and Confidental

Please ask the patient the following questions
Have you had any recent illness?
Have you been hospitalised recently?
Are you having any medical care at present?
Have you or any members of your family ever come into contact with persons exposed to BSE?
Have you had any operation, particularly operations to the face?
Have you ever had any of the following? (select as appropriate)
Are you allergic to any of the following? (select as appropriate)
Any other allergies?
Do you suffer from diabetes?
How is your diabetes controlled?
Do you take any of the following medicines?
Do you suffer from?

Females Only

Are you expecting?
Do you take oral contraceptives?
Have you had a hysterectomy?
Are you past the menopause?
Any other aspect of your health you think your dentist should know?

General Assessment of Dental Health

Oral hygiene
Please select which of the following attachments you are sending with this online referral
Additional files
Maximum upload size: 67.11MB
Please select other records you are sending by post

Confirmation

Checkboxes *