Oral Surgery Referral Form
(PLEASE COMPLETE ALL FIELDS)
Patient’s name
Dr 
Mr 
Date of birth
Mrs
Miss
Male / Female
Ms 
Address
(including postcode)
Daytime telephone
number
Patients GP Practice Name
Mobile telephone
number
Patient’s NHS number
Name of referring dentist (print name):
NHS Performer Number:
Practice Name / Address:
NHS Provider Number:
Telephone number
Date of referral
Reason for Referral (please tick):
MAXILLO-FACIAL SURGEONS IN SECONDARY CARE
 Patients needing general anaesthesia (GA) or sedation
 Suspected malignant disease (should be referred on
urgent 2 week wait form)
 Intractable or undiagnosed facial pain
 Symptomatic/undiagnosed orofacial disease
 Temporo-mandibular joint problems resistant to
conservative measures
 Treatments of patients with complex medical conditions
requiring multidisciplinary medical care
 Maxillofacial trauma / deformity
 Severe orofacial infection
 Dental implant patients requiring multi-disciplinary care
(subject to priorities panel approval)
 Salivary gland disease
 Soft tissue oral lesions
 Surgical exposure/removal supernumeraries
 Patients on IV bisphosphonates
 Other. Please give details below:
SPECIALIST ORAL SURGEONS IN
PRIMARY CARE
 Complex surgical extraction of teeth
 Apicectomies
 Extraction of teeth following previous
failed (GDP) extraction
 Treatments of patients with complex
medical conditions, including those on
warfarin whose INR is unstable and
those on long term steroids
 Patients for which a specialist opinion
is required, e.g. to assist diagnosis
 Post operative complications following
extraction in GDS
……………………………………………………………………………
Tooth (teeth) requiring treatment
Berkshire MOS Referral Form – February 2013
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87654321/12345678
Relevant patient dental history
NB: A relevant medical history signed by the patient MUST be attached to this form
Indication for
Sedation/GA
Dental phobia /
high anxiety
Difficult dental
procedure
Strong gag reflex
Poor-co-operation
If removal of third molars requested – please indicate reason within NICE guidelines
Please
tick
Surgical removal of impacted third molars should be limited to patients with evidence of
pathologyPlease indicate reason for referral for removal of wisdom teeth
Caries in lower third molar not amenable to restorative measures
Associated follicular cystic changes
Lower third molar contributing to periodontal disease of second lower molar
External or internal resorption of third molar
Recurrent episodes of pericoronitis
Restorable caries affecting distal aspect of second molars (evidenced with radiograph)
Good quality radiograph(s) must be attached or e-mailed securely
to Berkshire.MOS@nhs.net
Please staple to the back of this form.
If not attached please explain why
Number
Date Taken
For patients suitable for secondary care please indicate their preferred hospital
Wexham Park

Royal Berks

Frimley Park

Other (please specify):______________________
If the patient is assessed as suitable for treatment in a Primary Care Practice, what is patient’s preferred
location for treatment? Tick One
Inspire Dental, Oxford Road, Reading
Puresmile, Earley, Reading
Rodericks, Newbury



Crownwood Dental, Bracknell
Wexham Road Dental Surgery, Slough
Wexham Road Dental Surgery, Datchet



Dentist must sign to indicate that the patient has agreed the choice of provider which has been
offered to the patient and that the reasons for referral have been explained to the patient.
Signature of referring GDP:……………………………………………. Date: ………….............
Referring Dentist to send this referral form and relevant enclosures to:
Berkshire MOS Triage Service, Oxfordshire Salaried Primary Care Dental Service
Astral House, Granville Way, Bicester OX26 4JT
Tel: 01869 604040 E-mail: Berkshire.MOS@nhs.net
Berkshire MOS Referral Form – February 2013