This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
Presenting Complaint
Main presenting complaint:
- Other lump / swelling
- Other oral mucosal lesions
- Oral / facial pain
- Salivary gland problems
- Temporo-mandibular joint problems
- Oro-facial disproportion / deformity
- Requiring minor oral surgery
Based upon the answer to the question above, please select the appropriate option from the questions below.
If ‘Oral/Facial pain’ is selected, no further information is required here.
If ‘Temporo-mandibular joint problems’ is selected, no further information is required here.
If ‘Other lump/swelling’:
- Oral
- Facial
- Neck
If ‘Other oral mucosal lesions’:
- Long-term mucosal pigmented lesion
- Other mucosal abnormality
- Mucosal bullous lesion
- ROAU
If ‘Salivary gland problems’:
- Major gland
- Minor gland
- Salivary calculus
- Dry mouth
If ‘Oro-facial disproportion / deformity’:
- Skeletal growth abnormalities
- Cleft lip palate
- Post traumatic abnormalities
If ‘Requiring minor oral surgery’:
- Third molar/impacted tooth
- Other tooth/root
- Peri-radicular
- Pre-prosthetic
- Pre orthodontic
Reason for Referral: [Text]
Priority:
- Routine
- Urgent
- Urgent – Suspicion of cancer
Date of Onset: [Date]
Priority Reason: [Text – 98 character maximum]