Dental Referral Form PDF Details

Streamlining patient care in the dental field hinges upon effective communication and coordination among healthcare providers. The Dental Referral Form, sanctioned by the Canadian Dental Association, serves as a vital conduit for this purpose. Through a structured format, this document captures essential details ranging from the referring entity to the specified recipient, focusing on a seamless transition for the patient from one care provider to another. It records comprehensive patient information, including the patient's name, the parent or guardian's name if applicable, contact details, and pertinent medical and dental history. The form outlines the reason for the referral, whether it is for consultation or specific treatment, and guides the specialist on areas of concern, utilizing the F.D.I. tooth numbering system for clarity. Additional sections underscore any relevant medical or dental history that could influence diagnosis and treatment plans, ensuring any allergies or specific medical problems are highlighted. Moreover, it includes crucial logistical details about follow-up communications, aligning on whether the patient or referring dentist will initiate further contact, and instructions regarding the handling of radiographs and other records. By fostering a detailed exchange of information, the Dental Referral Form aims to optimize patient outcomes, underscoring the collaborative effort required in providing specialized dental care.

QuestionAnswer
Form NameDental Referral Form
Form Length1 pages
Fillable?Yes
Fillable fields16
Avg. time to fill out3 min 31 sec
Other namesgeneric dental referral form, printable dental referral forms, blank dental referral form, dental referral template

Form Preview Example

STANDARD DENTAL REFERRAL FORM

APPROVED BY THE CANADIAN DENTAL ASSOCIATION

FROM: ________________________________________________ _ _ _ _ _ ___

TO: _________________________________________________ _ _ _ _ _ ____

_______________________________________________________

__________________________________________________________

_______________________________________________________

__________________________________________________________

_______________________________________________________

__________________________________________________________

We are referring:

 

 

Patient:

_____________________________________________________

Parent/Guardian: ________________________________________________

Birthdate:

_____________________________________________________

Telephone:

________________________________________________

 

(M / D / Y)

 

 

Address:

_____________________________________________________

 

 

_____________________________________________________

_____________________________________________________

Telephone: _____________________________________________________

REASON FOR REFERRAL:

❏CONSULTATION RE: ____________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

❏TREATMENT (as requested):

(Please provide specialist with appropriate details of problem; i.e. urgency, areas of concern, using F.D.I. tooth numbering system.)

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

RELEVANT HISTORY:

(Indicate any special factors – either dental or medical – such as known allergies and specific medical problems relevant to diagnosis and treatment.)

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

❏ Please call the patient.

❏ Please report – written

❏ Patient will call.

❏ Please report – by phone

❏ An appointment has been made.

❏ Post-referral maintenance ❏ By specialist

_____________________________________

❏ In this office

❏ Radiographs are enclosed.

❏ To be discussed

❏ Please return radiographs after use.

 

❏ Notify on completion.

❏ Other records are available.

SIGNED: _____________________________________________________________________________DATE: ______________________________________

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standard referral form pdf completion process explained (part 1)

2. Soon after filling out the last section, head on to the subsequent step and fill out the necessary details in all these fields - RELEVANT HISTORY, Indicate any special factors, Please call the patient Patient, Radiographs are enclosed Please, Please report written Please, and By specialist In this office To.

Please call the patient Patient, By specialist In this office To, and Radiographs are enclosed Please of standard referral form pdf

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How one can fill out standard referral form pdf portion 3

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