Restorative Referral Form (July 2020)

During the COVID-19 pandemic, the Restorative Department at Leeds Dental Institute is only able to accept high priority referrals that require specialist intervention only. This referral form will be reviewed in

December 2020

ALL SECTIONS MUST BE FULLY COMPLETED, and the form signed at the end to confirm acceptance of the referral criteria. Failure to complete all parts of the referral form will result in it being returned to the referring dentist. Please note that the Restorative Department has a limited capacity for new referrals during the COVID-19 pandemic.

REFERRAL CATEGORY: Please select which of the following categories this referral relates to. A non-high category referral may not be accepted if the requested treatment modality falls outside of the guidance.

1. DOES THE PATIENT FIT INTO ONE OF THE FOLLOWING HIGH PRIORITY CATEGORIES?

• Developmental anomalies that require specialist advice/treatment

• Recent dental trauma requiring urgent specialist intervention – see full guidance

• Head and neck oncology

2. WHICH TREATMENT MODALITY IS THIS REFERRAL PERTAINING TO?

Fixed & removable prosthetics – cases with significantly altered anatomy (e.g. cleft or maxillectomy) or congenital abnormalities (e.g. amelogenesis imperfecta)

Periodontology – cases where every effort has been made to gain periodontology stability, there is excellent oral hygiene, and the patient is a non-smoker. Only grade C disease, disease associated with medical comorbidities such as unstable diabetes mellitus, or cases requiring localised surgical intervention. Please see existing referral guidance. Peri-implantitis management is reserved for NHS commissioned implants.

Endodontology – cases where the tooth shows a developmental anomaly (dens in dente, open apex, etc.), complex dental trauma or medical reasons to avoid an extraction. Please see existing referral guidance.

Implants – Refer to the RCS Eng. guidance on the standards of care for NHS-funded dental implant treatment for the patient groups considered eligible for NHS-funded dental implant treatment. Referrals will be assessed case-by-case basis.

We are currently unable to accept routine referrals e.g. Tooth surface loss, failing bridgework, unsatisfactory dentures, routine endodontic treatment / re-treatment, etc.

The referring dental practitioner must confirm that the patient is otherwise dentally stable and has:

• Good oral hygiene / dental hygiene

• Had treatment of all carious lesions, lost or fractured restorations, other endodontic pathologies

• Had treatment to stabilise periodontal disease

• An urgent need for specialist restorative intervention during the COVID-19 pandemic

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PRACTICE DETAILS

Referrer Name: Date of referral:

Practice address:

Postcode:

Tel:

Fax:

Email:

PATIENT DETAILS

Name: Date of birth: (must be >16 y/o at time of referral)

Sex: Female Male

Contact address:

Postcode:

Tel (Home/work/mobile):

NHS no/Hospital no:

Medical history:

Please state which service you would like: Diagnosis & treatment planning Treatment

Charting of teeth present:

BPE score:

*ALL cases with a BPE score of 4 require a6-point pocket chart and plaque scoreattached to the referral

Please provide a brief history of the problem being referred and synopsis of recent intervention. Detail on the reason why this patient requires specialist restorative advice or treatment is required. Please attach all relevant radiographs and photos to the referral – periodontal, endodontic and trauma referrals WILL NOT be accepted without radiographs.

SIGNATURE:

Date Signed:

SAVING & SUBMITTING THE FORM

Please and email it to leedsth-tr.dental-booking-office@nhs.net from an NHS.net email account.

leedsth-tr.dental-booking-office.net

Please also include any radiographs or clinical photographs taken.

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Referrer Name: Please provide a brief history of the problem being referred AND synopsis of recent intervention Detail on the reason why this patient requires specialist restorative advice or treatment is required Please attach all relevant radiographs and photos to the referral periodontal endodontic and trauma referrals WILL NOT be accepted without radiographs: Anomalies: OffTrauma: OffH&N Oncology: OffRemovable Pros: OffPerio: OffEndo: OffImplants: OffPractice Address: Practice Postcode: Fax: Phone: Email: Date: Patient Name: Paitent NHS/Hospital Number: Medical history 1: Medical history 2: D&T Planning: OffTreatment: OffGroup5: OffPatient address: Patient Postcode: Text20_es_:date: Patient Phone Number: Date23_es_:signer:date: RESET FORM: Text33: Text34: Text35: Text36: Text37: Text38: 1: Off4: Off2: Off3: Off5: Off6: Off7: Off8: Off9: Off10: Off11: Off12: Off13: Off14: Off15: Off16: Off17: Off18: Off19: Off20: Off21: Off22: Off23: Off24: Off25: Off26: Off27: Off28: Off29: Off30: Off31: Off32: OffText42: SAVE: