Dental Services Referral Form - Paediatric Dentistry Page 3
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4Requirements checklist
Additional
Current OPG less than 12 months old. We acknowledge not all small children or
information
disabled patients can cope with obtaining an OPG but this should be routinely
required;
attempted prior to referral.
sent
attempted but unable to obtain
Bitewing / Periapical radiographs
sent
attempted but unable to obtain
Dental charting indicating any teeth requiring extraction
sent
attempted but unable to obtain
Accurate medical history
sent
Detailed clinical history relating to the presenting complaint e.g. presence of pain,
swelling, nocturnal pain, recurrent courses of antibiotics
sent
For patients where a general anaesthetic has been indicated:
A completed General Anaesthetic Patient Health Questionnaire. This can be found at
.au/prgm-mgmt/rdhm-specialist
sent
Clinical notes detailing more than two attempts at treatment by different operators
under local anaesthetic. Junior operators should seek assistance from more senior
operators prior to referring patients.
included in details section.
A definitive treatment plan.
Should this information not be included, the child will be referred to a general clinic where
care will be provided by an Oral Health Therapist. Should treatment not be possible in the
general clinic, they will be referred on to the Day Surgery Unit with radiographs and a
treatment plan. This will be discussed with the family. Referring clinicians should make
families aware of this arrangement in cases where appropriate information cannot be
obtained.
sent
attempted but unable to obtain
Screening clinician’s notes (RDHM use only):
Phone:
Referring Clinician details:
Or completed on behalf of
Please record provider type
Dentist
Oral Health Therpaist
Dental Therpaist
Dental Hygienist
Other
Clinic mailing address:
Revised September 2014
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