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 a treatment(s)

Please select one of the following options
Has the patient an acceptable stable vertical dimension?

IV Sedation

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

Endodontics

Endodontics

Has the tooth been assessed as restorable?
Do you want South Down Dental & Implant Clinic to restore the tooth after treatment?
Which of the following does the patient require:
Referrals without appropriate radiographs may not be accepted.

Maximum file size: 67.11MB

CT Scanning

CT Scan

Mandible (FOV)
Maxilla (FOV)
Mandible and Maxilla
Additional scan requirements
Align with:
Please tick the more appropriate statement
Format required by referrer
Transfer of CBCT data

Implantology

Implantology

Does the patient have dentures
Please select the following:
Does the patient have any bridges in place?
Has the patient been informed about the financial implications of dental implants?
8750

TMJ / Facial Pain

TMJ / Facial Pain

Select the following signs and symptoms that the patient is experiencing:

Clicking / pain in joint(s)
Reduced occlusal function
Stress / anxiety present?

Referring dentist details

Patient details

Medical History - Private and Confidental

Please ask the patient the following questions
Does the patient have any relevant medical history?
Does patient smoke?
Does patient consume alcohol?
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?
Do you have/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 currently take any medicines
Please select which medicines you currently take
Do you experience any of the following?

Females Only

Females Only

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?
Are you pregnant?

General Assessment of Dental Health

General Assessment of Dental Health

Oral hygiene
Gum disease present?
Gum disease grade
Please select which of the following attachments you are sending with this online referral
Additional files

Maximum file size: 67.11MB

Please select other records you are sending by post

Confirmation

Checkboxes *

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