Name:
Date of Birth:
MRN Number:
NHS Number:
(or affix hospital label here)
Third Molar Removal
Referral Form
Referral To:
Gloucestershire Royal Hospital 
Cheltenham General Hospital 
Date of Referral:
Patients referred for consideration for the surgical removal of third molars must satisfy one or more of the
National Institute of Clinical Excellence (NICE) indications for treatment (see overleaf)
Patient Details:
DoB:
Male 
Home Tel:
Work Tel:
Mobile Tel:
NHS referral 
Private referral 
Name:
Female 
Address:
Postcode:
All medical conditions, allergies/reactions and medications:
Radiographs
Following discussions with the PCT Dental Advisor we have been advised that we must request that all relevant
radiographs are included with the referral letter to allow adequate assessment of the referral. If the radiographs are
of insufficient quality, or not enclosed, we will regretfully return the referral to you until such time as we are in
receipt of a suitable radiograph. Should the referring dentist not have suitable radiography equipment, a referral
can be made to the hospital radiology department who will take an OPG that the dept of OMFS can access, to
allow assessment of referral and further treatment. Hospital X-ray request forms can be downloaded from the OMF
departmental website.
Radiographs included? YES 
NO 
N/A 
If YES, please state type:
TO BE FILED IN THE PATIENT HEALTH RECORD
GHNHSFT/Y0776/04_13
TO BE FILED IN THE PATIENT HEALTH RECORD
GHNHSFT/Y0776/04_13
The General Dental Practitioner is requested to indicate the appropriate criteria for each third molar
requiring removal as indicated
Reason for Referral
1.
Dates of 2 or more episodes
of Pericoronitis
UR8
[ ]
Date:
Date:
Date:
UL8
[ ]
Date:
Date:
Date:
LR8
[ ]
Date:
Date:
Date:
LL8
[ ]
Date:
Date:
Date:
2.
Unrestorable caries in 8
[ ]
[ ]
[ ]
[ ]
3.
Distal caries in 7
[ ]
[ ]
[ ]
[ ]
4.
Non-restorable pulpal and /
or periapical pathology in 8
[ ]
[ ]
[ ]
[ ]
5.
Cellulitis, abscess or
osteomyelitis
[ ]
[ ]
[ ]
[ ]
6.
Periodontal disease 7 / 8
[ ]
[ ]
[ ]
[ ]
7.
Internal / external resorption
of tooth or adjacent teeth
[ ]
[ ]
[ ]
[ ]
8.
Fracture of 8
[ ]
[ ]
[ ]
[ ]
9.
Disease of follicle including
cyst / tumour of 8
[ ]
[ ]
[ ]
[ ]
10.
Orthodontic indications
(Please include orthodontist’s
request)
NB. Crowding of incisors is
not an indication for
removal of 8s
[ ]
[ ]
[ ]
[ ]
Less than 3 months
[ ]
[ ]
[ ]
[ ]
4 – 6 months
[ ]
[ ]
[ ]
[ ]
7 – 12 months
[ ]
[ ]
[ ]
[ ]
13 – 24 months
[ ]
[ ]
[ ]
[ ]
25+ months
[ ]
[ ]
[ ]
[ ]
Duration of
symptoms:
Signature of referring dentist:
Date:
Name of referring dentist (please print):
Address of referring dentist:
NB. Please ensure form is fully completed before submitting referral to OMFS Booking Office, GRH.
Incomplete forms will be returned to sender without an appointment being made.
TO BE FILED IN THE PATIENT HEALTH RECORD
GHNHSFT/Y0776/04_13