Polygon Dental

Tel: 023 8039 0090
Email: info@polygondental.co.uk

1 Kenilworth Road, Polygon, Southampton SO15 2GD

Oral Surgery Referral

    Patient Details

    Address

    Contact Phone Numbers & Email Address

    Referring Dentist Details

    Practice Name, Address & Telephone Number

    Treatment Required

    If other please specify

    Medical History

    Site: (please indicate)

    Upper Right

    Upper Left

    Lower Right

    Lower Left

    Reason for extraction, please tick box(es) below

    Non restorable tooth:

    Pulpal pathology (abscess/cellulitis):

    Periodontal pathology:

    Several episodes of pericoronaritis:

    Unsuccessful previous extraction:

    Orthodontics (Do we have the request from ortho specialist)

    Other (Please specify):

    Radiographs/OPG Taken (please include relevant radiographs):

    Oral Surgery referral criteria/extra information

    • Please ensure all forms come with an up to date medical history (bisphosphonates, blood thinners, etc)
    • Cost starts from £300 depending on difficulty and clinical time needed.
    • Please attach relevant radiographs (for assessment, a periapical radiograph or an OPG would be required). Please ensure radiograph shows the entire tooth and, at least, 3mm of the periapical area (bitewing radiographs are not acceptable for this purpose). See example underneath (a & b).

    Posterior PA Radiograph

    Posterior PA Radiograph