Queensway Dental Oral Surgery Referral Form

Level 2 Intermediate Oral Surgery Service Provider

*Please note that all fields are mandatory

Patient details

In accordance with policy referral protocols that can be found here.


Indication for sedation

(Please note we only manage ASA I and II Patients. ASA III may be suitable, but their care will be provided by exception – if unsure please contact us to discuss or refer to an appropriate secondary care service.)

NB: Please note this is not primarily a sedation service - for straightforward extractions on anxious patients please refer to the local sedation service. Please include ASA score, ie ASA1 and II (III by exception)

Weight limit*

Refer to separate guidelines and tick box as appropriate:

Translation services

GMP details

Referring dentist details

Before you submit the referral please tick...(*To be completed by the referring dentist)

  • I have explained to the patient the reason for referral and the choice of provider which has been agreed by the patient.
  • I have explained to the patient that their first appointment will be for assessment only and to bring along an up to date prescription (if applicable).
  • I have made the patient aware of any other dental care required to be managed by the referring practice.
  • I have read and understood the referral guidelines for referrals of this type and have included appropriate x-rays (or where not included have explained reason), medical history and medication
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*Updated 2023*