Minor Oral Surgery Referrals Patient name Patient address Patient postcode Patient date of birth Patient telephone Patient email Full comprehensive medical history (inlcude alcohol intake & recreational drug use) Patient medication Smoking status SmokerNon Smoker Tooth/teeth to be extracted IV Sedation Required? (If 'Yes' please include Height / Weight / BMI) Referring Dentist Name Referring Practice Referring Practice Address Referring Practice telephone Contact email Diagnostic X-rays (these must be attached) 5mb limit per file. Jpg, Png or Pdf accepted Additional Radiographs Additional Radiographs Additional Radiographs Additional Radiographs
