King's College Hospital nhs foundation Trust. Dental Institute



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King's College Hospital NHS Foundation Trust. Dental Institute

Dental Waiting List Office, Denmark Hill, London SE5 9RS
email kch-tr.dentalmaillist@nhs.net

Tel 020 3299 4988





Specialist Opinion only Specialist treatment Undergraduate treatment


WHICH DISCIPLINE SHOULD SEE THE PATIENT: TICK ONE ONLY*






Hypodontia, cleft etc


Other, please specify

REASON FOR REFERRAL & RELEVANT MEDICAL / DENTAL HISTORY




Radiographs: please include any relevant radiographs taken in past 12 months


Is there any other information we need to know?





General Medical Practitioner

Practice

Name & address

of GP:


Name:


This information is required to identify the Primary Care Trust of referred patients and to enable the GP to be copied into relevant correspondence by the consultant. Patients’ should bring the details of their GP to the hospital when they attend


Sex (please tick)


A. Patient Personal Details

Patient’s Surname:

Female


Patient’s Forename:


Surname (family name) at birth (if different):


Male

Contact Address:
House Name

or Number and

Street Name

Town or City:


Postcode:


Does your patient need to communicate in a language or mode other than English? If yes, please specify:

GDP Stamp / Address

Signed:

(Dentist)

if manual copy


I confirm that this patient referral comes within the current referral guidelines issued by Kings Dental Institute
Please tick box to confirm



Print Name

(Dentist)



Review date: March 2013


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