Rdhm Periodontics Referral Form - Dental Health Services Victoria Page 3
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4Requirements checklist
Additional information
Current OPG less than 12 months old
required;
sent
Bitewing and periapical views of diagnostic quality as appropriate
sent
not required
Clinical history to include details of symptoms and any previous treatment
including use of antibiotics
sent
not required
Treatment history (dates of initial therapy, review appointment findings and
charting).
sent
Periodontal charting of two O’Leary plaque index scores (including probing
depths, mobility, bleeding / discharge, and a demonstrated improvement in
plaque scores).
sent
Accurate medical history
sent
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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