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Get UK NHS BCHFT Dental Service GA Referral Form 2011-2024

Of Birth Age Address Home Tel. No. Contact Tel. No. Post Code Patient Dental History: Are they a regular attender? (This box must be completed) YES/NO Give details, i.e. what treatment, if any, have these children experienced? How do they react in a dental surgery? Justification for referral and alternative methods discussed or attempted. (a) Local anaesthesia with or without sedation has been offered but has proved inadequate or been refused *YES/NO (b) Local anaesthesia is contraindica.

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