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Dublin Dental University Hospital - lincoln dental group
445135609600Dublin Dental School and Hospital ORAL MEDICINEREFERRAL LETTER00Dublin Dental School and Hospital ORAL MEDICINEREFERRAL LETTER18669015621025590501759585Yes No Yes No 24638001821815?00?27406601821815?00?2667001831339Concern re Oral / Head & Neck Cancer0Concern re Oral / Head & Neck CancerConsultant / receiving practitioner and/or specialty clinicHospital and Hospital addressDATE:REFERRAL TODepartment of Oral MedicineDublin Dental School and Hospital Lincoln Place,Dublin 2.Or email to patient@dental.tcd.ieConsultant / receiving practitioner and/or specialty clinicHospital and Hospital addressDATE:REFERRAL TODepartment of Oral MedicineDublin Dental School and Hospital Lincoln Place,Dublin 2.Or email to patient@dental.tcd.ie4667254572000PATIENT DETAILSPatient’s addressSurnameForename(s) Previous SurnameTelephone no.SexMFOr ContactAgeDate of BirthE-Mail00PATIENT DETAILSPatient’s addressSurnameForename(s) Previous SurnameTelephone no.SexMFOr ContactAgeDate of BirthE-Mail340995017716500frf401002568580001304925123825?00?900430128905?00?40100251098550018764251479550401002543815004400557129780REFERRING PRACTITIONER DETAILSPractice addressNameEmail address Telephone no.00REFERRING PRACTITIONER DETAILSPractice addressNameEmail address Telephone no.34347158486160847725748665008763001040130008756651323975004667258648700REGISTERED GP DETAILS (Medicine)Practice addressNameEmail address Telephone no.00REGISTERED GP DETAILS (Medicine)Practice addressNameEmail address Telephone no.28079706355080005060950635508000CLINICAL INFORMATIONPlease complete all sections to facilitate appropriate triage of your referral.? Proformas with insufficient detail will be returned for completionHistory of presenting complaint/ examination findings/ investigation resultsReason for referralPast Medical HistoryCurrent and recent medicationClinical warnings (e.g. allergies, blood-borne, viruses)Smoking statusAlcohol consumption126873076200No per day00No per day-499110274955Duration00Duration-7175566675-8064563500-499110104775Ever Smoked00Ever Smoked-76200104775Yes ?0Yes ?-90170103505No ?0No ?Additional relevant information69215215900Social History (eg. Employment)13525535877400Special Needs (eg. Wheel Chair) Phobia8572540005Yes ?00Yes ?152400254000No ?0No ?Please enclose any pertinent photographs where available-47625312420Triage Stamp400000Triage Stamp3448050122555DateSignature of referring doctor (or other professional)(Legible Please)00DateSignature of referring doctor (or other professional)(Legible Please)
