Rdhm Periodontics Referral Form - Dental Health Services Victoria Page 2
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4Periodontic Clinic: For clinical criteria, exclusions, and patient information –
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Reason for referral:
Treatment urgency
Urgency 1: Suspected malignancy, trauma,
medical priority, patients to be seen the
Examination and treatment
same day
Opinion only
from information provided
Urgency 2: Patient experiencing pain
from examination of patient
Urgency 3: Patient not experiencing pain
Are you referring this patient to more than one RDHM Clinic?
No
Yes – please specify the other RDHM clinic(s)
Domiciliary Services
Endodontics
Implant
Oral Medicine – Mucosal
Oral Medicine - Facial Pain & TMD
Oral & Maxillofacial Surgery
Orthodontics
Paediatric Dentistry
Periodontics
Prosthodontics - Fixed
Prosthodontics – Removable
Special Needs
Details for the referral:
Patient’s / Person Responsible’s main concern / dental needs (in their own words):
Briefly describe how the service requested fits in your overall treatment plan.
Summary of medical history:
(please attach patient’s current full history)
Notable issues
Summary information
Details
attached
Physical or sensory
Sight
Hearing
Physical
None known
impairment
Intellectual impairment
Learning
Behaviour
Communication
None known
Falls Risk / Pressure
Falls Risk
Pressure Injuries
None known
Ulcers
Medications
Prescribed
Self administered
None known
Allergies / ADR
Allergy
Adverse Drug Reaction
None known
Other significant risks
Yes
No
None known
Revised September 2014
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Parent category: Medical