Dentist Referrals

NHS minor oral surgery patient referral form

Click here to download and print a referral form or Click here to fill out the form online.


    Patient Details

  • Dentist Details

  • Medical History

    Has the patient ever had or does he/she suffer from any of the following?

  • Declaration by dentist:

    I confirm that these details are accurate and contemporaneous. I have discussed all treatment options with the patient. I am enclosing with this referral relevant radiographs as requested.

    I understand that the patient may not be seen if the referral is incomplete.

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